COClMeu  UBRARIES  OFFSlTE 


<'*■•: 


C601  .Sa9 


RECAP 


♦      » 


V 


•»j  M'^^i ■>.'...  *   ..     jL  : 


►'      -I 


•  • "     *:   r      V.-,  . 


^:*^;^^-^ti:J'^t.i;'*'" 


:^j5lr4^ 


w 


^5 


-.' *C v^-fe^ 


*  t 


§'^r---^h 


\)    '4'      'r  'e    j^  ***■.- ■ 


1012  Walnut  Street, 

PHILADRLPHIA 


•    Ji 


.2££2i 


<^a^ 


mtljeCttpuflrttitork 

CoUese  of  $f)p£(ittansi  avib  S>urgeonJt 

Hibvavp 


^ 


Qy-KM^tJir 


^ 


CLINICAL   MANUALS 


FOR 


Pkactitioners  and  Students 
OF  Medicine. 


Insanity 


AND 


Allied  Neuroses 


PRACTICAL  AND    CLINICAL, 


GEORGE    H.    SAVAGE, 

M.D.,  M.E.C.P., 

PHYSICIAN     AND     SUPERINTENDENT     OF     BETHLEM      KOTAL      HOSPITAL: 

LECTURER  ON   MENTAL   DISEASES   AT   GUT'S    HOSPITAL  ;     JOINT 

EDITOR  OF   "the  JOURNAL  OF  MENTAL   SCIENCE." 


WITR    19    ILLUSTRATIONS. 


FHILABELPHIA : 
HENRY    C.    LEA'S    SON    k    CO. 

188i. 


SAMUEL  WILKS,  Esq.,  M.D.,  F.R.C.P.,  F.R.S., 

Senior  Physician  to  Guy's  Hospital, 
IN     GllATEFUL     ACKNOWLEDGMENT     OF     HIS     TEACHING     AND     HIS 

FKIENDSHIP, 

THIS    WORK    IS   DEDICATED   BY 

THE   AUTHOR. 


0.? 


f 


PEEFACE. 


To  those  who  have  been  engaged  for  years  in  the 
culture  of  any  branch  of  science,  and  in  the  imparting 
of  its  data  to  others,  there  naturally  comes  a  time 
when  the  facts  observed,  and  the  apparent  relations 
between  them,  seem  to  demand  some  permanent 
registration.  One  has,  as  it  were,  to  take  stock  of 
one's  facts  and  see  what  has  been  learnt.  I  have  for 
some  time  felt  that  my  period  of  observation  without 
registration  must  terminate,  and  that  I  owe  it  to  my 
position  as  physician  to  a  large  hospital  to  give  the 
younger  members  of  my  profession  the  results  of  my 
more  than  twelve  years'  experience  in  Bethlem. 

In  this  book  I  shall  describe  insanity  and  trace  its 
life  history.  I  shall  explain  the  legal  relationships  of 
the  insane,  and  make  plain  the  duties  of  the  physician 
who  has  to  be  responsible  for  their  safety  and  welfare. 
Although  the  greater  portion  of  this  work  will  bo 
the  record  of  my  own  personal  experience,  I  shall  have 
also  to  draw  upon  the  experience  of  others  when  treat- 
ing of  idiocy,  epilepsy,  and  chronic  mental  disorders, 
because  in  Bethlem  such  cases  are  not  treated. 


vi  Insanity  and  Allied  Neuroses. 

In  conclusion,  I  must  thank  many  who,  in  one 
way  or  another,  have  helped  me  in  my  work  ;  specially, 
W.  Haigh,  Esq.,  who  has  not  only  corrected  my 
proofs,  but  has  by  criticism  aided  me  much  in  the 
legal  chapters  ;  and  Dr.  F.  Beach,  who  has  contributed 
to  the  chapter  on  idiocy. 

G.  II.  S. 

Bcthlem  Roijol  ITospitaly 
October,  1884. 


CONTENTS. 


CHAPTER  PAGE 

I.  -What   is   meant  by  Insanity— Insanity  from 

Legal  and  Medical  Standpoints      ...  1 

II.— Classification  .........  10 

III.— Causes  of  Insanity,  Predisposing  and  Exciting  16 

IV.— Hysteria  and  its  Relationships     ....  80 

v.— Acute  Mania 99 

VI.— Hypochondriasis  and  Melancholia      .       .       .  128 

VII.— Melancholia 151 

VIII.— Dementia— Acute  Dementia 207 

IX.— States  of  Mental  Weakness 221 

X.— Delusional  Insanity— Hallucinations        .       .  237 

XI.— Moral  Insanity 269 

XII.— General  Paralysis  of  the  Insane        .       .       .276 

XIII.— Paralytic  Insanity 351 

XIV.— Puerperal  Insanity 360 

XV.— Epilepsy  and  Insanity 382 

XVI.— Brain  Tumours— Multiple  Sclerosis    .       .       .389 

XVII.— Syphilis  and  Insanity 392 

XVIIL— Relationships  between  Insanity  and  Pxiiiri.-^i.i 

PULMONALIS 396 

XIX.— Heart  Diseage  and  Insanity 40i 


VIU 


Insanity  and  Allied  Neuroses. 


CHAPTER 

XX.— Diabetes  and  Insanity  . 
XXI.— Alcoholism  and  Insanity    . 
XXIT.  -Idiocy  and  Imbecility  . 
XXIII. —Responsibility  of  Lunatics 
XXIV.— Legal  Relationships  of  Insanity 

Appendix "  . 

Index     


PAGE 

.  411 

.  419 

.  437 

.  460 

.  483 

.  522 

.  533 


iK^SAmTY  A^^D  Allied 

Neuroses. 


CHAPTER   I. 

WHAT    IS    MEANT    BY    INSANITY INSANITY    FROM    LEGAL 

AND    MEDICAL    STANDPOINTS. 

Introductory — Insanity  may  depend  on  disease  of  any  part  of  the 
body  —  Eccentricity  —  Genius  —  Crime  —  Borderland  between 
sanity  and  insanity. 

I  SHALL  not  discuss  normal  psychology  in  this  manual, 
because,  to  my  mind,  the  time  has  not  come  for  the 
re-arrangement  of  our  ideas  on  mind  and  its  physical 
basis. 

I  feel  strongly  that  as  long  as  mind  is  supposed 
to  be  located  in  the  skull  we  shall  make  little  progress. 
Though  I  have  examined  sections  of  brains  of  patients 
dying  from  almost  all  forms  of  insanity,  I  am  left 
with  the  feeling  that  we  must  be  more  general  in  our 
pathology  if  we  are  to  understand  our  subject. 

The  first  question  naturally  is,  what  is  meant  by  in- 
sanity 1  I  shall  try  to  show  clearly  throughout  this 
work  that  no  standard  of  sanity  as  fixed  by  nature  can 
under  any  circumstances  be  considered  definitely  to 
exist.  "  Sanity  "  and  "  insanity,"  as  recognised  by 
the  doctor,  and,  in  fact,  by  the  general  public,  must  be 
but  terms  of  convenience.  No  person  is  perfectly 
sane  in  all  his  mental  faculties,  any  more  than  he  is 
perfectly  healthy  in  body. 
B— 14 


2  Insanity  and  Allied  Neuroses.      [Chap.  i. 

There  are  flaws  on  the  physiological  side,  and 
defects  on  the  mental.  Insanity  has  to  be  looked  upon 
from  two  different  aspects.  From  the  physician's  side 
it  has  to  be  considered  as  a  disease  of  the  brain, 
or  a  disorder  of  the  mind,  quite  apart  from  any 
consideration  of  responsibility  whatever.  From  the 
other  side,  that  is,  as  seen  by  ordinary  members  of 
society,  insanity  is  scarcely  recognised  until  it  inter- 
feres, in  one  way  or  another,  with  the  laws  that  bind 
society  together.  Later  on  I  shall  trace  the  origin 
of  some  of  the  most  marked  forms  of  insanity,  and  I 
shall  be  able  to  point  out  that  the  earliest  symptoms 
of  unsoundness  of  mind  can  often  be  traced  far  back 
into  a  period  in  the  lives  of  the  patients  when  they 
were  apparently  fulfilling  every  social  and  moral 
duty.  Even  at  this  time,  from  the  medical  point  of 
view,  these  people  were  sufi'ering  from  unsoundness  of 
mind,  which  would  in  the  end  destroy  both  body  and 
mind.  It  will  be  my  duty  chiefly  to  consider  in- 
sanity from  the  physician's  point  of  view,  and  in 
doing  so  we  shall  see  that  a  man's  sanity  is  to  be 
gauged  purely  by  what  is  his  own  normal  standard. 

A  man,  in  fact,  must  be  considered  as  sane  or 
insane  in  relation  to  himself.  The  old  and  oft- 
repeated  statement  that  insanity  is  a  perversion  of  the 
ego  is  absolutely  true.  Sanity  and  insanity,  then, 
are  to  be  measured  by  differences  or  changes  of  habit, 
taste,  and  disposition  in  the  individual,  as  well  as  by 
other  symptoms  of  change  in  the  nervous  centres. 
The  difference  will  necessarily  be  seen  to  be  one  not 
only  of  degree,  but  one  of  time,  so  that  a  man  being 
sane  now  may  be  insane  within  a  longer  or  shorter 
period.  I  shall  take  it  for  granted  that  insanity  de- 
pends upon  change  in  the  nervous  structures  of  the 
body ;  but  by  no  means  shall  I  restrict  the  causa- 
tion of  insanity  to  changes  in  the  brain  alone.  Many 
cases  will  have  to  be  considered  in  which  the  insanity 


Chap.  I.]  Eccentricity.  3 

depends,  in  my  opinion,  upon  irritation  propagated 
along  nervous  tracks  at  a  distance  from  the  nerve 
centres.  Some  may  think  that,  in  extending  my  ideas 
of  insanity  as  far  as  'I  seem  to  do  in  the  above  para- 
graph, I  am  going  too  far.  But  the  more  I  see  of 
insanity,  the  more  convinced  I  am  that  the  considera- 
tion of  mental  disorder  can  only  be  fairly  approached 
by  the  complete  consideration  of  general  physiology, 
i.e.  the  development,  growth,  and  decay  of  the  body 
in  all  its  parts.  No  development  or  growth  can  go  on 
without  the  action  of  the  nervous  system.  Insanity 
may  depend  upon  vices  of  development,  vices  of 
growth,  or  premature  degeneration,  local  or  general ; 
but  it  may  depend  also  upon  the  bad  ministration 
of  the  servants  of  the  brain.  As  an  old  writer  has 
said,  "The  brain,  like  a  gentleman,  has  many  servants, 
but  withal  may  be  badly  served."  Insanity  may 
seem  to  depend  upon  physical  changes  which,  at 
first  sight,  seem  to  have  little  or  nothing  to  do  with 
the  brain.  Thus  it  does  not  need  a  physician's  expe- 
rience to  know  how  dependent  one  is  for  energy  and 
power  of  work  on  good  digestion.  The  relation  which 
exists  between  feelings  of  dyspepsia  and  states  of 
melancholy  must  be  fully  recognised.  For  though 
some  geniuses  have  been  dyspeptic,  the  world's  work 
is  best  done  by  people  who  eat  well  and  breathe 
freely. 

Insanity,  as  I  have  said,  is  a  relative  term,  and  it 
is  necessary  that  I  should  point  out  the  other  nervous 
conditions  to  which  it  is  allied.  Many  people  are 
considered  only  eccentric;  and  from  the  abnormally 
emotional  life  often  led  by  men  of  genius,  genius  is 
looked  for  as  the  necessary  accompaniment  of  eccen- 
tricity ;  at  least,  to  be  eccentric  suggests  an  idea  of 
genius.  (1)  Eccentric  people  may  belong  to  two  classes 
at  least :  those  who  have  some  insane  inheritance  (those, 
in  fact,  who  are  on  the  borderland  of  insanity),  and 


4  Insanity  and  Allied  Neuroses.      [Chap.  i. 

those  wlio  are  passing  from  sanity  into  some  form  of 
mental  disorder,  and  wlio  may  again  pass  through  this 
disturbed  mental  borderland  on  recovery.  (2)  Eccen- 
tricity  may  be  developed  de  novo  just  as,  I  believe, 
certain  forms  of  mental  perversion  may  be  developed. 
I  think  injustice  has  been  done  to  man's  power  of 
development  and  of  self-government  by  those  who 
would  look  to  the  parent  for  every  quality,  good  or 
bad,  possessed  by  the  offspring.  The  human  being 
comes  into  the  world  with  powers  of  development  of 
a  most  extraordinary  kind,  and  there  is  hardly  any 
limit  to  the  power  of  accommodation  to  the  environ- 
ment but  that  of  simple  pliysical  possibility.  It  is  a 
necessity  that  certain  persons  of  unstable  disposition, 
being  surrounded  by  unnatural  circumstances  and 
conditions,  should  develop  abnormal  properties.  Thus, 
the  person  who,  being  somewhat  niggardly,  has  begun 
by  collecting  trifles,  such  as  pins,  sardine  boxes,  horse 
shoes,  and  the  like,  may  end  in  shutting  himself  up  in 
an  attic,  in  refusing  to  wear  clothes,  and  being  un- 
willing even  to  wash,  for  fear  of  the  cost  of  soap  and 
water.  Such  cases  are  looked  upon  as  eccentric,  and 
I  might  fill  a  book  in  simply  narrating  instances  of 
eccentricity  as  seen  outside  asylums.  Most  persons 
have  both  tricks  of  body  and  tricks  of  mind  ;  have 
their  own  idiosyncracies  of  temperament,  as  we  should 
say.  If  the  one  or  the  other  is  not  duly  restrained 
and  checked,  a  habit  is  in  process  of  development 
which  may  influence  for  evil  the  whole  life  of  the 
individual.  Eccentricity  may  appear  in  any  one  of 
the  various  departments  of  mental  life ;  so  that  one 
person  may  be  suspicious,  another  may  be  jealous, 
another  subtle  and.  untruthful,  while  a  fourth  may  be 
violent,  passionate,  and  revengeful.  All  these  are 
properties  of  the  sound  mind,  if  in  due  subordination ; 
but  if  left  unrestrained,  or  stimulated  in  growth  by 
foolish  encouragement,  their  tendency  is  to  make  men^ 


Chap.  I.]  Genius.  5 

in  the  first  place,  eccentric,  and  afterwards  possibly 
to  form  the  groundwork  of  an  attack  of  insanity. 
Eccentricity  is  rarely  developed  before  the  period  of 
advanced  middle  life  :  or,  at  least,  is  not  recognised 
as  such.  The  peculiarities  in  younger  persons,  which 
are  allied  to  eccentricity,  are  considered  to  belong  to 
hysteria  or  moral  insanity,  and  I  am  inclined  to  think 
they  are  justly  so  classed.  These  latter  may  be,  and 
for  the  most  part  are,  cases  of  an  undeveloped  dis- 
order, which,  later  in  life,  is  almost  certain  to  assume 
an  acute  form,  and,  as  such,  many  of  them  undoubtedly 
bear  a  blood  relationship  to  the  more  marked  forms  of 
mental  unsoundness.  In  former  days  a  greater  num- 
ber of  eccentric  people  were  at  large  than  at  present, 
and  many  of  these  were,  without  doubt,  like  the  weak- 
minded  persons  who  are  now  condemned  to  the 
county  asylums.  To  conclude  this  short  notice  of 
eccentricity,  I  would  remark  that,  once  fairly 
developed,  it  is  probably  incurable. 

I  have  incidentally  referred  to  genius  in  its  con- 
nection with  eccentricity  and  insanity.  I  am  hardly 
prepared  to  give  a  definition  of  genius,  though  I 
would  call  attention  to  the  fact  that  it  is  usually 
associated  either  with  some  special  incomprehensible 
faculty  for  the  dramatic  portraiture  of  self-existent 
abnormal  emotion ;  or  altogether  dependent  upon  a 
simple  over-development  of  an  individual  faculty  of 
mind.  The  first,  in  a  sense,  we  may  call  the  genius 
of  art ;  the  latter,  that  of  science.  With  regard  to 
genius,  I  must  say  that  it  is  an  exception  to  find 
patients  with  unusual  capacity  of  any  kind  amoug 
the  inmates  of  an  asylum.  There  may  be  found 
"  specialists "  of  every  character  and  degree,  that  is, 
men  with  persistence  in  limited  pursuits ;  thus,  I 
have  known  a  patient  in  Bethlem  who  devoted  years 
to  the  delicate  polishing  of  pebbles ;  and  another 
whose  one  object  in  life  was  to  clean  windows,  while 


6  Insanity  and  Allied  Neuroses.      [Chap.  i. 

tlie  speciality  of  a  third  was  still  more  limited,  for 
his  sole  aim  was  to  keep  bright  the  brass  knobs  of  the 
water  taps.  Therefore,  from  the  point  of  view  of  the 
superintendent  of  an  asylum  for  acute  cases  of  mental 
disorder,  I  can  definitely  say  that  it  is  rare  to  meet 
with  extraordinary  ability  among  the  insane.  On  the 
other  hand,  I  must,  however,  admit  that  in  my  ex- 
perience of  people  out  of  asylums,  who  have  been 
credited  with  genius,  I  have  met  with  many  who 
possessed  marked  mental  peculiarities  and  eccen- 
tricities. It  appears  as  if  there  were  for  each  ordi- 
nary person  an  average  quantity  of  nervous  power 
and  energy  to  be  expended,  and  if  a  larger  amount 
than  usual  is  got  rid  of  in  one  direction,  there 
naturally  results  a  deficiency  in  some  other  quarter ; 
in  fact,  there  is  loss  of  balance.  "  Want  of  balance  " 
fairly  describes  the  mental  condition  of  many  a  genius. 
How  often,  for  example,  has  one  met  with  a  man  of 
letters,  the  man  of  taste  and  of  energy,  who  objected 
strongly  to  be  controlled  in  his  lower  or  more 
animal  tastes  !  Thus  it  happens  that  so  many  men  of 
genius  have  given  themselves  liberty,  if  not  license. 

Another  way  in  which  to  look  upon  the  relation- 
ship between  genius  and  insanity,  is  to  consider 
'precocity.  The  old  proverb,  "A  man  at  five,  a  fool 
at  fifteen,"  very  well  illustrates  what  is  frequently 
seen.  Precocious  children  are  commonly  the  off- 
spring of  insane  or  nervous  parents.  I  have,  myself, 
had  in  Bethlem  one.  female  patient,  whose  two 
children,  both  under  six  years  of  age,  were  playing 
classical  music  in  public.  I  have  seen  other  children 
who  developed  almost  in  infancy  strong  animal  pas- 
sions. When  considering  idiocy,  I  shall  have  to  dis- 
cuss more  in  detail  the  disorders  incidental  to  infancy 
and  childhood,  and  therefore  I  now  leave  this  part  of 
the  question  of  precocity,  merely  stating  that,  in  my 
experience,  the  children  of  the  insane  may    develop 


Chap  I.]  Borderland  of  Insanity,  7 

certain  aptitudes  or  passions   at  the  expense  of  the 
rest  of  their  nervous  development. 

The  special  aptitudes  are  for  music,  sometimes 
for  art  and  mathematics,  and  a  wondeiiully  retentive 
memory  may  be  present.  Tt  is  rare  to  see  such  a 
child  with  all  these  talents  developed  at  one  time, 
but  it  is  common  to  see  a  child  with  one  or  more  of 
these  who  is  totally  wanting  in  moral  sense.  I  shall, 
nnder  the  head  of  "  moral  insanity,"  and  when  con- 
sidering "  hereditary  neurosis,"  give  details  of  such 
cases.  One  naturally  passes  from  these  considera- 
tions to  the  relationships  of  crime  to  mental  un- 
soundness. I  shall  have  to  devote  a  chapter  more 
especially  and  fully  to  this  matter.  But  here  I 
speak  only  of  the  borderland  of  insanity,  which 
has  been  so  carefully  explored  by  Dr.  Maudsley. 
There  can  be  no  doubt  in  the  minds  of  those 
who  see  much  of  the  criminal  classes  and  of  those 
who  see  much  of  the  insane  classes,  that  there 
is  something  in  common  between  them.  I  must  not 
be  misunderstood  in  saying  this,  for  there  is  an 
immense  difference  between  some  insane  persons  and 
some  criminals ;  but  as  the  savage  and  the  statesman 
have  connecting  links  between  them,  so  among  cri- 
minals and  lunatics  there  are  many  grades  which 
approach  one  another  very  closely.  To  begin  with, 
the  j^hysical  aspect  of  a  chronic  lunatic  resembles 
very  closely  that  of  a  confirmed  criminal,  and  the 
mental  degeneration  of  man  leaves  his  features  so 
changed  and  debased  that  he  resembles  the  man  who, 
from  vice  of  birth  or  faulty  surroundings,  has  never 
developed  the  higher  social  qualities.  As  Dr.  Mauds- 
ley  has  well  pointed  out,  "  Though  there  is  a 
borderland,  there  is  no  boundary  stone  ;  and  there 
are  cases  in  which  exist  some  insanity  and  much 
crime,  and  others  with  much  insanity  and  little 
crime."     And  at  present  this  borderland  is  the  one 


8  Insanity  and  Allied  Neuroses.      [Chap.  i. 

on  which  most  forensic  battles  have  to  be  fought. 
Though  from  theoretical  points  of  view  it  may  appear 
that  any  one  with  criminal  tendencies  must  be  looked 
upon  as  insane  (as  one,  in  fact,  who  cannot  be  calcu- 
lated upon,  and  whose  actions  are  not  governed  and 
controlled  as  are  those  of  the  ordinary  social  unit), 
yet  society,  as  represented  by  lawyer,  judge,  and  jury, 
will  continue  to  hold  the  balance  in  its  own  hands, 
and  punish  those  who  may,  after  all,  be  of  unsound 
mind,  the  expert's  opinion  notwithstanding. 

The  relationships  of  insanity  to  crime  are  further 
evidenced  by  the  fact  that  so  many  criminals  develop 
other  nervous  disorders  while  under  punishment  for 
their  offences.  Epilepsy  is  much  more  common 
among  criminals  than  among  the  sane.  Sense  per- 
versions are  mujh  more  common  among  them  also. 
They  appear  wanting  in  the  highest  of  all  mental 
power,  the  power  of  controlling,  or  organising  and 
applying,  what  faculties  they  possess.  Their  nervous 
systems  are  unstable  and  easily  break  down.  These 
facts,  important  as  they  are  to  the  student  of  mental 
physiology,  can  at  present  hardly  be  applied  in  the 
treatment  of  the  criminal.  Though  the  relationship 
must  be  fully  recognised,  it  would  be  no  more  fair 
to  say  that  crime  and  insanity  are  directly  connected 
(that  is,  generally  connected),  than  it  would  have 
been  fair  to  say  that  genius  and  insanity  were 
similarly  allied. 

The  test  of  family  relationship  must,  after  all,  be 
connection  by  paternity.  If  a  large  proportion  of 
criminals  can  be  found  having  insane  parents  or 
insane  children,  it  must  be  admitted  that  there  is 
some  closer  connection  between  insanity  and  crime 
than  mere  accident.  And  if  we  can  trace  the  de- 
velopment of  criminal  instincts  to  insane  parentage, 
if  we  can  prove  the  direct  transmission  of  criminal 
instincts  from  father  to  son,  we  shall  have  done  much 


Chap.  I.]       PosT-MoRTEM  Examinations.  9 

to  show  that  there  are  true  links  between  intellectual 
and  moral  perversion. 

In  speaking  of  the  inheritance  of  neurosis,  I  shall 
have  to  give  instances  in  which  some  members  of  a 
family  have  been  insane,  while  others  have  been 
"ne'er-clo-weels,"  and  perhaps  one  member  has  be- 
come criminal.  In  the  borderland  now  under  con- 
sideration there  are  other  tracks  to  be  explored,  and  I 
shall  have  to  point  out  that  hysteria,  hypochondriasis, 
epilepsy,  somnambulism,  and  other  allied  states,  are 
all  at  least  more  nearly  related  to  mental  unsound- 
ness than  to  sanity.  I  am  anxious  not  to  be  sup- 
posed to  be  of  the  opinion  that  every  perversion  of 
nervous  action,  every  unusual  display  of  intellectual 
or  moral  force,  is  to  be  regarded  as  a  case  requiring 
the  interposition  of  the  physician  whose  chief  care 
has  been  for  the  insane.  But  till  insanity  is  looked 
upon  as  a  phase  of  bodily  disorder,  till  it  is  seen  to 
be  related  to  all  the  other  disorders  of  the  nervous 
centres,  it  will  not  be  justly  appreciated  and  properly 
treated.  Insanity,  although  associated  with  nervous 
disorders  and  change  in  the  nervous  tissues,  cannot 
yet  be  localised  ;  we  cannot  say  that  a  patient  suf- 
fering from  acute  mauia  has  certain  nutritional 
changes  in  his  brain. 

One  of  the  greatest  difficulties  which  has  ever  pre- 
sented itself  to  the  student  of  insanity  has  been  the 
fact  that  post  mortem  so  little  has  been  found  visible 
to  the  naked  eye.  I  may  say  that,  with  my  expe- 
rience of  years,  and  after  seeing  many  hundreds  of 
jjost-mortem  examinations  of  the  bodies  of  the  insane, 
I  have  met  with  few  coarse  changes  within  the  skull, 
and  even  with  the  higher  powers  of  the  microscope  all 
that  can  often  be  detected  may  be  evidences  of  change 
in  the  nutrition  of  the  connective  tissue  of  the  brain. 
This  may  seem  unsatisfactory ;  but  the  time  will  come 
when  the  inter-relations  between  the  millions  of  nerve 


lo         Insanity  and  Allied  Neuroses.     [Chap.  ii. 

cells  witli  their  manifold  processes,  and  their  depen- 
dence for  healthy  action  upon  healthy  blood  and  pure 
air,  will  be  better  understood.  The  brain,  like  a 
kaleidoscope,  consists  of  innumerable  parts,  which 
adapt  themselves  to  varying  patterns.  A  shake 
occurs,  the  pattern  changes,  but  each  one  of  the  pieces 
still  exists-  as  it  did  before  ;  no  change  in  shape,  no 
change  in  colour,  only  change  in  relationship.  So,  I  be- 
lieve, it  will  be  found  to  be  with  many  forms  of  insanity, 
change  in  one  faculty  changing  the  mental  pattern. 


CHAPTER    II. 


CLASSIFICATION. 


Ideal    classification — Classification    of     the    London    College    of 
Physicians — Author's  classification. 

We  may  classify  by  the  causes,  as  in  epileptic, 
puerperal,  or  alcoholic  insanity;  or  by  the /brms  which 
the  symptoms  assume;  thus,  mania,  melancholia,  or 
dementia. 

We  may  divide  cases  according  as  to  whether  the 
senses  are  at  fault,  or  the  reasoning  faculty  is  per- 
verted. We  may  arrange  as  to  whether  the  disorder 
arises  in  connection  with  development,  growth, 
maturity,  or  decay,  or  whether  the  disease  arises 
primarily  in  brain  disease,  or  is  secondary  to  other 
bodily  illness.  Further,  special  faculties  may  suffer 
chiefly  or  primarily,  the  senses  being  disordered  may 
lead  to  insanity ;  the  organic  or  the  reproductive  sides 
of  a  man  may  be  disordered  ;  his  judgment  and  will 
may  suffer ;  memory  or  the  moral  sense  may  be  want- 
ing. Insanities  may  be  acute  or  chronic,  recurrent  or 
circular ;  they  may  be  curable  or  incurable.  I  sub- 
join an  ideal  classification,  the  classification  which  is 
accepted  by  the   London  College  of  Physicians,  and 


Chap.  II.]         Scheme  OF  Classification. 


II 


finally,  the  classification  which  for  convenience  I 
follow. 


shall 


SCHEME    OF    CLASSIFICATION. 


Insanity  of  early  deve- 
lopment ^ 

Causes  of  insanity  of  ^ 
I  cMldliood 

I  Forms  of  insanity  in 
I  cMldhood  "^ 


Insanity  of  adolescence  \ 


Insanity  of  maturity  .  < 


Insanity  of  climacteric 


'  Idiocy,  from  brain  deficiency. 
Idiocy,  from  sense  deficiency. 
Idiocy,  from  inability  to  develop. 
.  Imbecility,  from  inability  to  develop  fully. 
'  From  congenital  causes. 
From  epilepsy. 
From  injury  or  brain  disease. 
Mania. 
Melancholia. 
Moral  perversion. 

Due  to : 
Onset  of  sexuality,  masturbation. 
Stress  of  work. 
Phthisis,  etc. 

(Nervous  system  only  fit  for  low  pres- 
sure). 
Symptoms : 
Mania  with  conceit. 

Emotional  melancholia  and  hypochon- 
driasis, with  liability  to  recnr,  and 
tendency  to  mental  weakness. 
Mania. 
Melancholia. 
Dementia, 
General  paralysis  due  to  strain  or  excess. 

(  Delusions. 
In  women  <  "Persecutions." 

(  Hallucinations. 
In  men  :  Often  hypochondriacal,  due  to 
visceral  Oreak-down. 


Insanity  of  age 


r  Mania. 
A  Melancholia. 
(  Dementia. 


All  tend  to  dementia. 


NOMENCLATURE    OF    ROYAL    COLLEGE    OF    PHYSICIANS. 


IMania. 

Melancholia. 

Dementia,    including    acqu.ired 

imbecility. 
Idiocy,  congenital  imbecility. 
General  jiaralysis  of  the  insane. 
Puerperal  insanity. 
Epileptic  insanity. 
Insanity  of  puberty. 
Climacteric  insanity. 


Senile  insanity. 

Toxic  insanity,  alcohol,  gout, 
lead,  etc. 

Delirium  tremens. 

Traumatic  insanity. 

Insanity  associated  with  obvious 
morbid  change  or  changes  in 
the  brain. 

Consecutive  insanity,  from  fe- 
vers, visceral  inflammations. 


12         Insanity  and  Allied  Neuroses.     [Chap.  ii. 

So-called  cases  of  monomania  should  be  named  according  as 
the  prevailing  symptoms  are  those  of  mania,  melancholia,  or 
dementia ;  and  distinct  hereditary  tendency  should  be  mentioned. 

I  purpose  making  use  of  the  following  groups  in 

my  manual  : 

Hysteria — Mania. 

Hy  pochon  driasis — Melancholia. 

Dementia,  general  and  partial,  primary  and  secondary. 

States  of  mental  weakness — Chronic  mania  and  melancholia. 

Recurrent  insanity. 

Delusional  insanity. 

General  paralysis  of  the  insane. 

Paralytic  insanity — Epilei^tic  insanity. 

Puerperal  insanity — Post-connubial,  puerperal,  lactation. 

Toxic  insanity — Alcohol,  lead,  opium,  chloral,  etc. — Gout. 

Visceral  insanity — Renal,  cardiac,  pulmonary. 

Insanity  with  syphUis — Myxoedema — Grave's  disease — Asthma 

— Diabetes. 
Idiocy  in  its  various  degrees. 

Any  classification  of  insanity  must  necessarily  be 
provisional.  At  all  events,  till  our  knowledge  of  mind 
in  health  and  disease  is  greatly  extended,  I  shall  divide 
the  cases  we  are  to  consider  into  what  I  have  found  to 
be  convenient  groups ;  if  not  classes  or  orders  in  the 
kingdom  of  disease,  they  represent  sufficiently  defi- 
nite collections  of  symptoms  to  bear  general  descrip- 
tions. They  are,  in  fact,  definite  enough  to  enable  the 
student  of  medicine  to  classify  any  cases  which  come 
under  his  care  according  to  them.  The  classification 
will  in  many  particulars  be  a  cross  classification,  so 
that  certain  cases  will  ajipear  under  different  headings. 
The  time  may  come  when  a  classification  of  mental 
disorders  may  be  according  to  the  physiological  changes 
which  take  place  in  the  nerve  centres.  In  my  pre- 
sent classification,  I  shall  feel  bound  to  recognise 
the  fact  that  certain  cases  of  insanity  are  due  to 
disease  of  the  brain  of  a  very  definite  and  observable 
character,  and  that  certain  other  cases  of  insanity  de- 
])end  for  their  origin  on  the  existence  of  some  bodily 
defect   or   degeneration,   which,   causing   irritation  at 


Ch.p.  II.]         Recovery  FROM  Insanity.  13 

the  periphery,  in  the  end  sets  up  brain  disease  by 
a  continuity  of  the  nervous  tissues,  or  by  some  other 
reflecting  process.  Unlike  most  ordinary  diseases,  an 
attack  of  insanity  does  not  either  pass  away  entirely, 
or  kill  a  patient,  but  in  the  majority  of  cases  leaves 
him  more  or  less  mentally  crippled.  The  physician 
has  often  recognised  the  fact  that  a  man  is  not  the 
same  after  having  a  serious  attack  of  illness.  A  man 
differs  in  one  or  more  particular  after  he  has  passed 
through  small-pox,  fever,  rheumatism,  or  even  gout. 
It  has  been  said  that  a  bee-master,  before  he  had  an 
attack  of  small-pox  was  able  to  handle  these  stinging 
insects  with  impunity^  but  after  his  recovery  he  was 
no  longer  able  to  follow  his  occupation,  the  bees  dis- 
continuing to  like  him,  and  even  not  tolerating  his 
presence.  I  myself  have  seen  several  patients  whose 
temper  and  dispositions  have  been  markedly  affected 
by  an  acute  illness  such  as  rheumatic  fever,  so  that 
a  patient  who  had  been  previously  of  quiet,  indus- 
trious and  domesticated  habits,  and  a  good  wife,  became, 
after  recovery,  a  selfish,  indolent,  home-neglecting 
person.  These  are  accidents  when  considered  in  rela- 
tionship to  general  bodily  diseases,  but  they  are  pecu- 
liarly common  when  associated  with  insanity.  The  large 
residuum  of  insanity  which  fills  our  county  asylums 
consists  to  a  great  extent  of  the  patients  who,  having 
had  one  or  more  attacks  of  insanity,  have  neither  died 
nor  recovered.  There  is,  in  fact,  a  very  strong  feeling 
prevalent  that  a  patient  once  having  had  an  attack 
of  insanity  is  never  cured  under  any  circumstances. 
This  I  shall  oppose  entirely ;  but  I  acknowledge  that 
a  very  considerable  proportion  are  maimed  in  one  way 
or  another  by  an  attack  of  insanity.  It  is  only  what 
might  be  expected,  for  the  more  delicate  an  instru- 
ment, the  greater  its  liability  to  injury  by  rough 
handling  or  rapidly  changing  conditions.  The  eye, 
itself  but  a  window  of  the  mind,  is  recognised  to  be 


14         Insanity  and  Allied  Neuroses.     [Chap.  ii. 

an  organ  which  suffers  permanently  from  slight  in- 
flammatory or  other  disorders,  which  did  not  appear  at 
first  to  be  of  much  importance.  Is  it  therefore  sur- 
prising that  the  still  more  highly  developed  and 
organised  human  brain  should  show  signs  of  storms 
that  sweep  over  it  % 

I  have  been  in  the  habit,  in  clinical  teaching,  of 
dividing  all  my  patients  into  the  curable  and  incu- 
rable, but  I  have  always  added  that  I  intended  in 
this  division  to  separate  those  patients  suffering  from 
general  paralysis  of  the  insane,  from  those  suffering 
from  every  other  form  of  nervous  disorder.  In  my 
clinical  division  of  insanity  I  make  the  symptoms,  or 
outward  signs,  the  points  of  division.  Thus  we  have 
mania,  melancholia,  dementia,  delusional  insanity,  and 
states  of  weak-mindedness.  Each  of  these  classes  will 
have  to  be  more  fully  subdivided  ;  and  a  more  natural 
form  of  division,  in  my  judgment,  is  that  which  I 
have  already  referred  to,  and  have  placed  at  the  head 
of  this  chapter. 

First  in  this  table  one  has  the  insanity  of  develop- 
ment, as  seen  in  the  arrests  and  perversion  of  children, 
ending  almost  invariably  in  idiocy,  or  in  imbecility. 
Attacks  of  nervous  disorder  affecting  the  unstable  de- 
veloping nervous  tissues  of  childhood,  cause,  as  may  be 
expected,  rapid  and  yjermanent  degeneration.  It  is, 
as  it  were,  a  destruction  of  a  house  of  cards. 

Next  is  the  insanity  of  adolescence,  and  here  we 
meet  with  the  same  forms  of  mental  disturbance,  but 
with  a  much  more  marked  character  than  as  seen 
among  children.  The  forces  are  greater,  perhaps  rather 
more  stable,  but  yet  eminently  mobile.  The  prognosis 
in  such  cases  will  be  better  than  among  children,  and 
less  satisfactory  than  among  the  mature. 

The  third  division  is  formed  by  the  period  of 
maturity,  and  here  we  meet  with  the  greatest  num- 
ber of  insane  patients.      Insanity  seems  peculiar  from 


Chap.  IT.]    Explanation  OF  Classification.  15 

this  characteristic,  that  at  the  period  of  fullest  vitality 
mental  disorder  is  most  common. 

It  has  to  be  recognised  that  in  this  we  often  see 
the  full  blowing  of  the  morbid  flower  of  insane  in- 
heritance. We  also  see  that  the  fine  brain  organism 
breaks  down  when  the  greatest  stress  is  thrown  upon 
it,  and  that  the  period  of  maturity  is  that  of  work, 
ambition,  disappointment,  and  of  the  uncurbed  exer- 
cise of  the  largest  number  of  faculties  of  body  and 
mind.  At  the  close  of  the  period  of  full  maturity 
comes  the  period  of  change,  the  so-called  climacteric 
or,  in  woman,  menopause.  Some  think  no  such  period 
occurs  to  men.  But  I  am  inclined,  from  my  ex- 
perience of  the  insane,  to  consider  that  (though, 
perhaps,  later)  a  similar  period  exists,  and  that,  in 
fact,  a  man  does  not  pass  from  maturity  into  old 
age  without  a  period  of  mobility  or  instability,  during 
which  he  is  assuming  habits  which,  if  duly  developed, 
are  conservators  of  energy.  The  last  division,  accord- 
ing to  age,  is  the  period  of  decay ;  and  I  shall  point 
out  that  there  are  many  varieties  of  nervous  death, 
some  being  rapidly  destructive,  and  others  leading 
slowly  to  euthanasia. 

I  think  it  necessary  to  make  some  divisions, 
according  to  the  parts  of  the  mind  that  seem  to  be 
affected  ;  and  I  shall  point  out  that  whereas  in  one 
case  loss  of  energy  is  seen  by  the  will-less  condition 
of  one  patient,  in  another  perversion  of  moral  nature 
may  be  so  great  as  to  justify  the  use  of  the  term 
moral  insanity. 

My  division  of  insanity  being  provisional,  and  in 
no  way  pretending  to  be  final,  will  be  found  more 
useful  than  elaborate  new  plans  which  would  entail 
labour  to  the  student  to  master,  and  which  will  in 
the  end  have  to  be  thrown  aside.  Moreover,  my 
classification,  being  on  the  old  lines,  will  be  understood 
by  all 


i6 


CHAPTER   TIL 

CAUSES    OF    INSANITY,  PREDISPOSING    AND    EXCITING. 

General  predisposing  causes  :  Effect  of  race — Education — 
Sex — Age — Neurotic  predisposition — Occupation — Heredity — 
Constitution  and  temperament.  Moral  causes  :  Domestic 
trouble — Mental  anxiety  and  overwork — ^Keligious  excitement 
— Love  affairs  (including  seduction) — Fright  and  nervous  shock. 
Physical  causes  :  Intemperance  in  drink — Intemperance 
(sexual) — Venereal  disease — Self-abuse  (sexual) — Over-exer- 
tion— Sunstroke — Accident  or  injury — Pregnancy — Parturition 
and  the  puerperal  state — Lactation — Uterine  and  ovarian  dis- 
orders— Puberty — Climacteric— Fevers — Privation  and  starva- 
tion— Old  age — Other  bodily  diseases  or  disorders — Previous 
attacks — Hereditary  influences  ascertained  (direct  and  col- 
lateral)— Congenital  defect  ascertained — Other  ascertained 
causes — Unknown  causes. 

In  this  chapter  I  shall  show  the  many  contributing 
conditions  which  may  aid  in  the  development  of 
insanity.  Insanity  rarely  springs  into  existence;  it 
begins  to  grow  long  before  it  is  seen. 

When  speaking  of  "  cause,"  I  use  the  term  in  the 
widest  sense  for  convenience,  and  not  pretending  to 
exact  expression.  The  sun,  the  rain,  the  dissolving 
soil,  the  very  earth-cast  of  the  worm,  contribute  to 
the  growth  of  the  grass,  and  in  a  sense  may  be  said 
to  cause  the  grass  to  grow;  so  it  is  with  insanity 
and  the  many  and  complex  relations  of  life.  I 
shall  consider  all  the  assisting  conditions  in  the 
environment  as  causes,  when  they  can  be  shown 
probably  to  have  influenced  the  result. 

Any  division  which  one  makes  must  be  artificial, 
and  suited  for  the  present  time  and  our  limited 
knowledge,  both  moral  and  physical.  Predisposing 
and  exciting  are  but  convenient  expressions  of  the 
immediate   conditions  connected    with    the    disorder; 


Chap.  III.]  Predisposing  Causes.  17 

the  effect  of  a  moral  shock  may  be  similar  in  kind  and 
in  degree  to  that  of  a  physical  one,  and  the  body  may 
suffer  in  the  same  way  from  each.  A  fright  or  a 
blow  may  produce  pallor,  faintness,  and  sickness  ;  and 
a  graver  shock  or  blow  may  produce  insensibility, 
or  mental  disorder  of  more  active  kinds.  Thus,  any 
division  depending  on  terms  like  moral  and  physical 
must  be  understood  to  be  used  for  convenience,  and 
not  as  representing  any  definite  idea  of  physiology 
or  psychology. 

Without  considering  the  terms  'physical  and 
psychical  as  final,  I  shall  make  use  of  them,  and 
I  have  adopted  the  rather  convenient  table  which  is 
approved  by  the  Medico-Psychological  Association; 
this  table  contains  the  chief  accepted  causes  which 
are  given  of  mental  affections. 

In  any  classification  we  must  refer  to  the  time- 
honoured  division  into  ^' predisposiTig "  and  "ex- 
citing "  causes.  The  "  predisposing  "  and  "  exciting  " 
causes  must  again  be  divided  into  general  and  special. 
Here  we  may  often  be  able  to  place  two  distinct 
events  or  conditions  which  have  precipitated  the  cata- 
strophe. Or  one  physical  cause  may  act  in  several 
directions  ;  thus  :  a  drunken  man  loses  his  situation, 
and  is  brought  face  to  face  with  want ;  drink  has  been 
preparing  the  brain,  and  the  shock  of  the  loss  of  his 
situation  is  just  sufficient  to  upset  the  already  un- 
stable balance.  Delirium  tremens  is  often  known  to 
follow  a  physical  shock  or  injury,  and  in  the  same 
way  I  have  known  a  sudden  mental  shock  to  produce 
insanity,  resembling,  in  many  particulars,  delirium 
tremens.  Thus,  I  saw  a  lady  suffering  from  acute 
mania  of  a  restless,  noisy  variety,  the  patient  being 
emotional,  and  at  night  seeing  vermin  about  her,  and 
strange  faces  on  the  walls  of  her  bedroom.  She 
had  been  a  secret  drinker,  and  having  been  left  a 
good  deal  alone  of  an  evening  by  her  husband,  had 
c— 14 


i8         Insanity  and  Allied  Neuroses.   [Chap,  iil 

had  ample  opportunities  for  indulging  her  evil  habits. 
She  had  been,  by  a  kindly  motive,  induced  to  go  out 
one  evening,  but  had  failed  to  get  home  in  conse- 
quence of  her  drunken  condition ;  she  had  been  cared 
for  in  a  police  cell,  and  the  next  morning  fined  five 
shillings.  The  loss  of  position  incurred  by  this  acci- 
dent upset  her  balance,  and  for  a  time  she  was  insane. 

When  considering  the  relations  of  drink  to  insanity 
in  detail,  I  shall  have  to  speak  more  fully  of  its 
double  action,  or  I  might  go  farther  and  say,  its 
multiple  action,  for  it  affects  the  mind,  body,  and 
estate  in  a  most  complex  way.  But,  whether  we 
consider  causation  from  the  side  of  predisposing  and 
exciting,  or  from  the  bodily  or  the  mental  side,  when 
we  come  to  life  studies  we  shall  very  rarely  find  one 
single  predisposing  and  one  single  exciting  cause. 
Generally,  when  persons  become  insane  they  do  not 
suddenly  jump  from  sanity  to  insanity  ;  the  whole 
thing,  as  a  rule,  is  a  morbid  development.  The  bodily 
and  the  mental  relations  become  changed  step  by  step, 
and  the  final  outbreak  of  insanity,  which  causes  the 
friends  to  seclude  the  patient,  is  but  the  last  step 
in  the  downward  course.  So  much  is  this  the  case, 
that  a  very  large  number  of  patients  are  sent  to 
asylums  with  the  earliest  recognised  symptoms  of 
their  disease  given  as  the  cause  of  the  affection.  By 
this  means  many  so-called  drink-produced  cases  are 
wrongly  accused  of  intemperance.  Sleej)lessness  may 
lead  to  the  use  of  stimulants,  and  these  in  their  turn 
upset  Uhe  digestive  functions,  and  the  patient,  thus 
weakened  and  exhausted,  loses  all  self-control  and 
becomes  mad. 

As  I  have  already  said,  predisposing  causes  are  to 
be  divided  into  the  general  and  special.  Many 
writers  have  considered  almost  every  one  of  the 
varying  conditions  of  civilised  life  as  possible  predis- 
posing causes  to  insanity.     In  fact,  any  one  of  the 


Chap.  III.]  Influence  of  Race.  19 

many-sided  parts  of  the  character  of  man,  when  over- 
developed, may  predispose  to  a  loss  of  mental  balance  ; 
and  doubtless  it  is  of  the  utmost  importance,  in 
studying  the  genesis  of  insanity,  to  consider  with  care 
anything  that  may  assist  in  the  fuller  understanding 
of  mental  action. 


GENERAL    PREDISPOSING    CAUSES. 

Effect  of  race. — It  has  been  supposed  that 
insanity  occurs  more  among  some  races  than  among 
others,  or,  at  least,  that  some  forms  of  insanity  are 
more  likely  to  appear  among,  say,  the  more  excitable 
races  than  among  the  phlegmatic.  But  evidence  is 
wanting  to  show  that  peculiarities  of  race  alone  are 
sufficient  to  cause  marked  differences  in  the  insani- 
ties. Por  though  excitement  and  excess  may  tell 
disastrously  upon  the  unexcitable,  I  am  inclined 
to  think  that  direct  nervous  stimulation  is  like  their 
native  sun  to  the  more  excitable  southerners,  a 
natural  and  constant  part  of  themselves.  An  amount 
of  excitement  or  excess  which  might  disturb  an 
Englishman  would  little  affect  the  Italian  or  Spaniard  ; 
and  statistics  clearly  show  that  insanity  may  occur 
at  least  as  frequently  among  the  slow-living  (I  had 
almost  said  torpid)  races  of  the  north,  as  among  the 
excitable  southerners.  In  Scandinavia,  causes  such 
as  solitude  act  as  disastrously  as  indolence  and 
excitement  among  other  races. 

Dr.  Ashe,  of  Ireland,  contributed  to  the  Medical 
Congress  of  1881  a  collection  of  statistics  showing 
the  infrequency  of  general  paralysis  of  the  insane 
among  the  Irish,  and  in  the  same  collection  were 
brought  together  statistics  from  other  Celtic  races. 
And  although  we  find  that  in  the  highlands  of  Scot- 
land and  in  the  rural  parts  of  Ireland  and  Wales, 
a  general  paralysis  of  the  insane  is  almost  unknown, 


20         Insanity  and  Allied  Neuroses.   [Chap.  iii. 

yet  as  soon  as  the  same  peojole  migrated  to  cities 
they  seemed  to  enjoy  no  immunity  from  this  disease, 
so  that  there  could  not  have  been  any  question  of 
purity  of  race  alone  as  giving  immunity. 

It  used  to  be  said  in  America  that  the  same  im- 
munity was  enjoyed  by  the  negroes  in  slavery ;  but 
whatever  the  cause  may  have  been  in  the  days  of 
servitude,  I  have  the  best  authority  for  stating  that 
general  paralysis  of  the  insane  occurs  now,  not  only 
among  negroes,  but  among  negresses  also.  I  know  of 
no  special  race-immunity,  either  from  ordinary  in- 
sanity, or  from  general  paralysis.  Recently  I  had 
an  opportunity  of  studying  the  condition  of  the 
Indians  of  north  Canada  in  the  Hudson's  Bay  Ter- 
ritory, from  the  notes  made  during  five  years  by  Mr. 
Walton  Haydon,  and  I  found  that  insanity,  associated 
both  with  excitement  and  depression,  occurs  among 
the  natives.  Few  opportunities,  however,  are  given 
for  the  study  of  such  patients,  for  among  imcivilised 
races,  to  be  mad  is  sufficient  reason  to  be  killed.  It 
might  be  supposed  that  some  races,  like  the  French 
branch  of  the  Latin  race,  were  specially  predisposed,  by 
reason  of  the  constancy  with  which  political  agitations 
disturb  the  whole  country  ;  but  it  is  noteworthy  that 
political  and  social  convulsions  do  not  greatly  increase 
the  numbers  of  the  insane,  and  that,  in  fact,  the  chief 
part  which  such  differences  play  is  rather  to  colour 
or  give  shape  to  the  disorder  than  to  cause  any 
marked  increase.  It  was  shown,  during  the  Franco- 
Prussian  war,  that  large  numbers  of  people  on  the 
borderland  of  insanity  seemed  rather  to  be  prevented 
from  passing  into  the  land  of  madness  by  the  mental 
excitement  and  occupation  afforded  by  those  stirring 
times.  In  fact,  it  did  what  one  is  constantly  striving 
in  vain  to  do,  it  gave  occupation  to  the  thoughts  of 
the  nervous,  thus  taking  them  away  from  the  insane 
contemplation  of  self. 


Chap.  III.]       Influence  of  Education.  21 

Education  has  to  be  considered  among  llie 
predisposing  causes.  And  here  it  will  be  found  that 
insanity  occurs  amongst  the  most  highly  educated,  as 
well  as  among  those  without  any  learning  at  all. 
Does  education  produce  insanity  %  Is  the  present 
age  of  school  boards  one  in  which  insanity  is  manu- 
factured by  overwork  %  These  are  two  of  the  most 
important  questions  which  present  themselves  for 
solution  at  the  present  day.  In  my  opinion,  true 
education,  that  is,  the  true  development  of  mind  and 
body,  are  the  best  preventives  of  insanity.  Over- 
education,  or  bad  education,  consists  really  in  the 
development  of  one  side  of  the  human  being  at  the 
expense  or  to  the  neglect  of  the  rest ;  and  the  fault 
which  one  constantly  sees  is  in  educating  the  child 
along  the  lines  to  which  its  tastes  lead  it  without 
paying  sufficient  attention  to  correlated  functions. 
The  precociously  artistic  child  is  encouraged  to  dabble 
in  colours,  and  the  musician  of  five  years  old  is  placed 
in  the  hands  of  a  master.  This  is  bad  education,  and 
is  likely  to  do  harm.  I  should  not,  however,  think  it 
well  to  follow  the  advice  of  a  recent  writer  who 
suggested  that  it  would  be  advantageous  if  all  men 
were  taught  to  be  ambi-dexterous.  For  although  it 
is  well  to  be  able  to  use  both  hands,  it  is  better  that 
one  should  be  more  facile  and  read}^,  rather  than  that 
both  should  be  indifierently  handy.  I  have  rarely 
seen  insanity  produced  by  anything  that  could  be 
fairly  called  over-education,  if  hygienic  rules  were 
followed,  and  if  patients  were  not  already  strongly 
predisposed  to  insanity  by  inheritance.  The  weak- 
mindedness  produced  by .  over-special  education  falls 
most  markedly  upon  those  who  have  insane  inheri- 
tance. As  has  already  been  stated,  precocity  is 
not  unusual  in  such  persons,  and  the  precocious  child 
is  one  often  having  intellectually  w^eak  parents,  who 
are      likely     to     mismanage     it    in    all    directions. 


22  iNSAmTY  AND    ALLIED    NEUROSES.     [Chap.  HI. 

A  forcing  process  goes  on  which  ends  in  a  premature 
decay  or  an  unnatural  production.  The  education 
which  I  have  seen  do  most  harm  is  that  which  may- 
be called  education  out  of  harmony  with  the  sur- 
roundings of  the  individual.  Thus,  the  promising 
artisan  who  wins  some  prize,  or  who  is  taken  up  by 
some  well-meaning  patron,  and  who  is  educated  in  the 
book  learning  of  the  ancients,  or  in  the  science  of  the 
moderns,  runs  danger  of  suffering.  I  have  constant 
examples  in  Bethlem  of  young  men,  who,  having  left 
the  plough  for  the  desk,  have  found,  after  years  of 
struggle,  that  their  path  was  barred  by  social  or 
other  hindrances,  and  disappointment,  worry,  and 
the  solitude  of  a  great  city  have  produced  insanity  of 
an  incurable  type.  The  question  of  the  number  of 
hours  of  daily  work  that  are  to  be  considered  sufficient, 
beyond  which  over- work  comes  in,  is  a  question  which 
must  depend  on  the  individual ;  and  in  dealing  with 
the  question  of  education  as  a  cause  of  insanity, 
I  insist  chiefly  on  the  disturbance  produced  by 
education  bad  in  quality  or  amount. 

A  strong  healthy  girl  of  a  nervous  family  is 
encouraged  to  read  for  examination,  and  having  dis- 
tinguished herself,  is,  perhaps,  sent  to  some  fashionable 
forcing  house,  where  useless  book  learning  is  crammed 
into  her.  She  is  exposed,  like  the  Strasburg  geese,  to 
stuffing  of  mental  food  in  over-heated  rooms,  and 
disorder  of  her  functions  results.  Or  if  a  similarly 
promising  girl  is  allowed  to  educate  herself  at  home, 
the  danger  of  solitary  work  and  want  of  social 
friction  may  be  seen  in  conceit  developing  into 
insanity.  It  is  in  this  manner  that  the  results  of 
defective  education  become  often  apparent  in  the  case 
of  the  weaker  sex  now-a-days. 

Finally,  with  regard  to  the  question  of  education, 
most  writers,  who  begin  by  stating  that  there  is  a 
great  increase  in  insanity,   end  by  saying  that  the 


Chap.  III.]  Influence  of  Sex.  23 

increase  is  due  to  the  increase  of  education,  and  that 
insanity  grows  directly  as  the  education  of  the  people 
increases.  But  this,  again,  to  my  mind,  needs  con- 
siderable qualification.  Now-a-days  education  has 
spread  far  and  wide ;  and  although  it  may  be 
theoretically  for  the  benefit  of  mankind  that  the 
larger  proportion  should  read  and  write,  and  have 
a  sufficient  knowledge  of  many  tilings,  yet  it  leads 
men  to  over-estimate  their  mental  acquirements  as 
compared  with  their  bodily  ability ;  so  that  the  fact 
that  a  very  large  number  of  clerks  become  insane  is 
rather  an  evidence  that  there  are  many  more  clerks 
living  struggling  existences,  than  that  the  study 
required  to  qualify  them  for  their  occupation  has 
caused  their  mental  disturbance.  With  the  increase 
of  education  are  produced  over-ambition,  feverish 
pursuit  of  gain  and  pleasure,  aggregation  in  towns, 
celibacy  with  vice  of  one  kind  and  another,  and  the 
development  of  religious  indifference  and  general 
unbelief,  associated  with  neglect  of  general  hygienic 
conditions. 

Sex. — Both  sexes  are  liable  to  insanity,  and  suffer 
from  acute  attacks  of  mania,  melancholia,  or  dementia, 
almost  in  equal  proportions.  But  some  forms  of 
insanity,  such  as  general  paralysis  of  the  insane,  are 
at  present  much  more  common  among  men  than 
among  women.  Whatever  the  cause  of  this  may  be, 
I  have  no  doubt  of  the  fact  that  insanity  of  this 
particular  type  is  greatly  on  the  increase  both  among 
men  and  women.  Even  in  my  recollection  of  the 
insane,  which  extends  over  a  period  of  a  little  under 
twenty  years,  I  have  noticed  U  marked  increase  in  the 
number  of  female  general-paralytics  seen  in  the  middle 
classes.  It  is  still  a  question  as  to  the  absolute  pro- 
portion between  the  number  of  insane  among  men 
and  women.  The  Commissioners'  returns  for  1883 
show:  in  private   asylums,  2,181   men,  against  2,617 


24         Insanity  and  Allied  N'euroses.   [Chap.  in. 

women;  and  in  pauper  asylums,  29,741  men,  against 
35,521  women. 

In  most  asylums  there  are  more  female  than  male 
admissions,  and  certainly  in  Bethlem  Hospital  we 
always  have  an  excess  of  female  patients,  and  this 
excess  is  regular  and  constant.  But  there  is  also  to 
be  considered  the  question  that  women  seem  to  be 
more  readily  cured,  and  are  more  liable  to  recurrences 
of  insanity,  so  that,  taking  the  number  of  females 
admitted,  they  would  not  exceed  the  males  in  such  a 
marked  degree,  though  still  they  would  be  in  excess. 
The  sex  makes  a  difference,  not  only  in  number,  but 
also  as  to  the  causation  of  the  insanity.  As  I  shall 
have  to  point  out,  one  of  the  most  dangerous  periods 
in  the  lives  of  nervous  persons  is  the  period  of 
puberty.  This  period  is  dangerous  to  men,  but  it  is 
much  more  so  to  women.  Everyone  is  familiar  with 
the  hysterical  girl ;  but  few  appreciate  at  first, 
at  its  full  value,  the  danger  of  the  onset  of  desire 
as  it  occurs  in  lads.  The  nervously  predisposed 
youth  might  well  be  represented  by  the  artist  as 
a  frail,  bloodless  body  being  struggled  for  by  the 
spirits  of  Eros  and  Psyche.  Women  are  more 
often  upset  by  sexual  troubles,  and  the  periods  of 
pregnancy,  parturition,  and  lactation  add  gravely  to 
the  danger  which  they  run  of  becoming  insane.  It 
must  be  fully  recognised  that  many  of  the  sexual 
perversions  which  occur  among  the  insane  are 
attributable  to  their  insanity,  and  are  not  to  be 
looked  upon  as  the  causes  of  the  disordered  con- 
dition. 

That  there  is  an  excess  of  female  lunatics  might  be 
expected  from  the  greater  nervous  instability  of 
women,  from  the  larger  number,  proportionately,  of 
women  living  at  any  one  time  in  England,  to  the 
greater  tendency  of  insanity  to  recur  in  women,  and 
to    the    greater    tendency    of   mothers    to    transmit 


Chap.  III.]  Influence  of  Age.  25 

insanity  to  their  female  children,  who  again  are  the 
more  numerous. 

In  connection  with  sex  one  must  consider  mar- 
riage. Among  the  insane  we  lind  among  men  most 
single  men,  but  among  women  more  married  than 
single  women.  And  here  we  must  remember  women 
marry  earlier  than  men,  and  have  extra  causes  of 
disturbance,  to  which  I  have  already  referred. 
Widows  are  much  more  liable  to  break  down  than 
widowers ;  and  this  is  comparatively  easily  explained. 
In  modern  society  marriage  is  looked  upon  as  the 
proper  social  end  of  a  girl's  life  :  she  is  educated 
for  and  led  to  expect  that  household  duties  will  be 
hers,  and,  as  a  rule,  she  is  hardly  prepared  for  any 
independent  struggle  with  the  world ;  and  if  for  a 
time  she  has  gone  out  as  governess  or  shop-assistant, 
it  has  been  only  with  the  idea  that  this  condition 
would  be  temporary.  When  married  this  is  all  given 
up,  her  accomf)lishments  become  neglected,  and  her 
family  is  made  the  centre  of  her  life.  If  accident  or 
disease  deprive  her  of  her  husband,  she  has  a  hard 
struggle  for  her  bread;  worries,  anxieties,  loss  of 
social  position,  and  deprivation  of  sexual  gratification, 
all  assist.  These  causes  are  sufficient  to  upset  the 
nervous  balance  of  a  large  number  of  women ;  so 
many,  in  fact,  that  I  often  feel  I  shall  have  to  de- 
scribe a  form  of  mental  disorder  under  the  name  of 
"  widows'  disease." 

A§"e. — I  believe  that  occasionally  children  come 
into  the  world  of  unsound  mind.  It  may,  however, 
seem  an  exaggeration  to  speak  of  the  mind  of  a 
newly  born  animal ;  but  I*  have  had  opportunities  of 
seeing  children  whose  mothers  have  been  in  Beth- 
lem  during  the  later  months  of  pregnancy  suffering 
from  insanity,  and  some  such  children  have  almost, 
from  the  hour  of  birth,  been  restless,  intractable, 
sleepless,  and  unnatural  little  creatures. 


26  IlSiSANITY  AND    AlLIED    NeUROSES.     [Chap.  III. 

Various  forms  of  brain  defect  or  disease  causing 
idiocy  may  occur  from  birth,  and  will  be  considered 
with  idiocy  later.  As  a  rule,  all  nervous  distur- 
bance of  a  severe  kind  in  early  infancy  leaves  the 
mind  a  wreck.  I  have  seen  acute  mania  and  acute 
melancholia  in  very  young  children ;  dementia,  apart 
from  idiocy,  can  scarcely  be  recognised  in  children. 

I  have  known  a  girl  of  eleven  years  of  age  who 
persistently  refused  food,  and  had  done  this  so  long 
that  her  whole  weight  was  only  thirty-four  and  a  half 
pounds ;  she  had  the  marked  skin  changes  seen  with 
starvation.  Kind  but  firm  treatment,  with  good 
feeding,  restored  this  child.  Dr.  Heron,  under 
whose  care  she  was,  says  he  has  traced  insanity  in 
one  parent's  family. 

The  next  period  of  special  interest  is  the  age  of 
puberty,  in  which  we  meet  with  various  forms  of 
insanity,  all  of  which  have  a  great  tendency  to 
culminate  in  weak-mindedness,  if  they  last  for  any 
considerable  period,  or  if  they  are  severe  in  degree. 
They  are  chiefly  characterised  by  emotional  distur- 
bance, by  exalted  ideas  of  power  and  worth,  or  by 
the  converse  feelings  of  unworthiness.  They  may  be 
associated  with  hypochondriacal  conditions  of  one 
kind  or  another,  the  patient  frequently  referring  the 
symptoms  to  the  head  or  brain,  and  assuring  you  that 
his  or  her  brain  is  either  dried  up  or  swollen.  At 
this  period  moral  perversions  are  very  common,  espe- 
cially if  there  is  strong  inheritance  of  insanity ;  lying, 
thieving,  lust,  cruelty,  and  destructiveness  being  not 
uncommon. 

A  lad  of  fifteen,  whose  mother  was  many  years 
ago  in  Bethlem,  and  whose  uncle  died  of  insanity, 
went  on  well  enough  till  he  was  set  to  work  in  an 
ofiice ;  he  became  restless,  and  though  able,  he  never 
stopped  long  in  a  place.  He  was  plausible  and  cun- 
ning,  and  thus  easily  got  fresh  situations.     It  was 


Chap.  III.]  Climacteric  Insanity.  27 

found,  after  a  time,  that  he  was  not  so  good  at  his 
work,  and  further  investigation  brought  many  of  his 
faults  to  light;  he  had  lied  persistently,  he  had 
destroyed  property,  and  valuables  which  had  passed 
through  his  hands  were  missing  or  injured,  and  yet 
none  of  these  things  could  be  brought  home  to  him. 
Such  a  case  will  probably  become  a  chronic  lunatic  or 
a  criminal.  This  is  the  age  when  insanity,  associated 
with  phthisis  pulmonalis,  is  not  uncommon. 

The  period  of  full  maturity  and  development, 
during  which  the  larger  proportion  of  nervous  dis- 
orders occurs,  next  occupies  our  consideration. 

Mania,  melancholia,  and,  occasionally,  primary 
dementia  are  met  with,  chiefly  at  maturity,  there 
being  endless  varieties  of  each.  This  age  is  the 
one  in  which  which  premature  decay,  as  seen  in 
general  paralysis,  makes  itself  recognised.  When 
reviewing  in  detail  the  causation  of  general  para- 
lysis of  the  insane,  I  shall  have  to  point  out  the 
fact  that  the  age  of  this  disease  is  the  age  of 
full  vitality.  It  appears  as  if  among  the  strongest, 
most  thoughtful,  most  energetic  and  useful  of  men, 
this  disease  has  its  richest  harvest.  I  shall  point  out 
that  there  are  many  other  diseases  of  the  body  which 
have  mental  sides  (if  I  may  use  the  term) ;  thus,  with 
gout  and  with  degenerations  of  various  organs,  we  may 
have  developed  melancholia,  hypochondriasis  or  symp- 
toms of  dementia.  Later  in  life  a  period  of  several 
years  occurs  in  which  melancholia,  especially  of  the 
hypochondriacal  type,  occurs.  In  women  this  is  re- 
cognised as  "  climacteric  insanity,"  and  I  shall  give  the 
same  name  to  it  whether  occurring  in  men  or  women. 
The  chief  characteristics  of  the  disease  are  feelings 
of  bodily  misery,  sleeplessness,  together  with  feelings 
of  spiritual  unworthiness.  This  is  the  age  of  ''unpar- 
donable sin."  Such  cases  frequently  recover  if  they  are 
judiciously  treated  for  a  snfiiciently  long  period.    For, 


28         Insanity  and  Allied  Neuroses,  fchap.  in. 

like  most  other  climacteric  conditions,  it  is  often 
years  before  the  fresh  balance  is  re-established.  The 
period  of  the  climacteric,  already  a  period  of  degene- 
ration, is  succeeded  by  a  still  more  fully  .marked 
decadence.  Life  is  drawing  to  a  close,  and  the 
weight  of  years  is  telling,  not  only  in  feebleness  of 
body,  in  impaired  digestion,  but  in  loss  of  control  of 
the  faculties,  or  marked  pain  in  their  action,  so  that 
painful  thought  or  brain-ache  occurs,  which  is  but 
another  way  of  describing  melancholia.  The  most 
common  result  of  mental  degeneration  is  a  return  to 
childishness,  and  this  childishness  may  be  approached 
somewhat  suddenly  or  more  gradually,  so  that  the 
old  person  may  pass  from  a  period  of  health  and 
strength  through  a  time  which  is  like  the  period 
of  adolescence,  and  is  associated  with  a  similar  in- 
stability and  tendency  to  emotional  disturbance. 
Second  youth  may  be  passionate  or  hysterical. 
The  mental  edifice,  tottering  to  its  fall,  may  be  still 
further  damaged  by  some  other  physical  accident. 
Thus,  apoplexy  may  comj)lete  the  intellectual  ruin 
begun  by  age,  the  whole  depending  on  a  further 
extension  of  arterial  disease,  the  brain  acting  feebly, 
and  being  but  poorly  nourished.  With  the  reduced 
supply  and  assimilation  there  are  fewer  and  fewer 
exhibitions  of  mind,  till,  the  supply  being  finally  cut 
ofi*,  the  end  is  reached. 

Wetirotic  iiilieritsaiice  a^iid  predispositioii. 
— In  general,  I  should  say  there  is  one  chief  predis- 
posing cause,  namely,  neurotic  predisposition.  This 
statement  may  be  said  to  be  like  Moliere's  explana- 
tion of  the  effect  of  opium  :  "  its  effects  were  sopo- 
rific." I  only  give  a  term  and  no  explanation;  but  I 
would  insist  in  my  belief  that  only  a  certain  number 
of  persons  are  so  constituted  that  they  can  become 
insane. 

Any  one  may  have  a  brain  tumour,  or  may  die 


Chap.  III.]  Neurotic  Inheritance.  29 

from  abscess  of  the  brain  j  probably  most  may  develop 
general  paralysis  of  the  insane,  but  I  believe  few  can 
become  "  insane."  Those  who  become  insane  may 
inherit  the  predisposition  directly ;  and  it  is  remark- 
able to  see  how  very  precise  the  similarities  of  the 
nervous  derangements  in  parents  and  children  may 
be.  I  have  known  one  member  after  another  of  a 
family  commit  suicide,  and  I  have  even  known  the 
members  of  one  family  to  possess  a  predilection  for 
the  mode  of  destroying  themselves.  I  have,  again, 
known  mother  and  daughter  break  down  under  the 
same  conditions,  as,  for  example,  after  childbirth.  It 
may  be  said  in  both  these  cases  there  was  a  great 
probability  of  the  relations  dwelling  on  the  fate  of 
their  friends,  and  begetting  the  evil  thought  by 
brooding  over  it ;  but  this  connotes  a  disposition  of 
subjectivity  which  is  in  itself  abnormal.  In  con- 
sidering, however,  the  predisposing  causation  of 
insanity  by  inheritance,  I  would  insist,  most  of  all, 
on  direct  inheritance  of  insanity.  First,  the  danger 
is  great,  the  nearer  the  begetting  of  the  child  is  to  the 
insanity. 

Thus  I  have  seen  one  girl  of  weak  mind,  who  was 
begotten  on  the  very  day  her  father  had  his  first 
convulsive  fit,  which  was  his  first  symptom  of  general 
paralysis  of  the  insane ;  here  there  was  no  doubt  about 
the  time  of  conception  possible,  from  the  wife's 
history.  Again,  a  patient  was  admitted  into  Bethlem 
whose  father  was  discharged  from  an  asylum  on 
leave,  partially  recovered,  nine  months  before  her 
birth  ;  and  I  was  consulted  in  another  case  in  which 
the  patient  was  begotten  by  a  father  who  was  on 
leave  from  an  asylum.  That  the  direct  inheritance  is 
of  the  utmost  importance  I  have  seen  evidenced  by 
the  fact  that  a  patient  in  Bethlem  Hospital,  suftering 
from  insanity  during  pregnancy,  bore  a  child  who 
was  insane  from  birth.     I  shall  have  to  refer  to  the 


30         Insanity  and  Allied  Neuroses.   [Chap.  iii. 

history  of  this  child  later,  and  need  say  no  more 
at  present  than  that  it  is  but  one  of  several  children 
born  of  insane  mothers,  who  have  been  perverse  from 
the  very  womb.  The  inheritance,  then,  is  direct  as 
to  time,  the  danger  being  greatest  during  the  period 
of  insanity,  and  immediately  before  and  after  it^  so 
that  I  have  known  many  cases  of  insane  patients 
whose  mothers  had  puerperal  insanity,  the  first  attack 
of  recognised  insanity  following  the  birth  of  the 
patient,  though,  doubtless,  the  factors  of  the  disease 
existed  earlier.  The  form  of  insanity  may  be  direct, 
that  is,  it  may  be  similar  in  parent  and  child ;  and 
the  insanity  may  affect  the  one  sex  more  than  the 
other,  but  this  does  not  always  follow.  I  have  known 
one  case  where  a  man  had  two  wives,  and  by  each 
wife  one  child,  a  boy  by  one  and  a  girl  by  the  other, 
yet  both  these  children  were  alike  nervously  un- 
stable, tht  father's  mother  having  been  a  lunatic. 

As  in  other  diseases,  so  here,  one  generation  may 
escape,  or,  rather,  may  pass  on  the  instability  without 
developing  it.  It  is,  hoAvever,  still  doubtful  what 
governs  the  inheritance;  and  it  seems  that  in  some 
cases  certainly  the  father  passes  his  insanity  more  on 
to  his  sons  than  to  his  daughters.  But,  in  my 
experience,  I  should  say  that  whereas  a  mother 
certainly  passes  her  tendency  to  nervous  disorder 
most  strongly  to  her  daughters,  a  father  very  gene- 
rally passes  it  to  both  sons  and  daughters  in  a  rather 
less  degree.  It  has  been  thought  by  some  that  a 
child  inherits  the  mental  characteristics  of  the  parent 
he  most  nearly  resembles  in  appearance,  but  this  is 
doubtful.  It  is  almost  certain  that  direct  inheri- 
tance is  the  most  dangerous,  and  that  the  danger 
is  greatest  if  the  father  is  insane  at  or  near  the 
time  of  the  begetting,  or  if  the  mother  is  insane 
during  or  soon  after  the  pregnancy.  I  am  not  sure 
as  to  the  amount  of  danger  to  the  offspring  when  the 


Chap.  III.]  Neurotic  Inheritance.  31 

mother  has  had  very  pronounced  insanity,  or  even 
insane  longings,  during  the  early  months  of  pregnancy, 
which  has  been  recovered  from  before  the  end  of  the 
pregnancy.  If  there  be  insanity  in  the  families  of 
both  parents  the  danger  to  the  offspring  is  greatly 
increased,  and  this  may  be  easily  accepted.  The 
common  dread  of  marriages  between  cousins  and 
other  blood  relations  is  due  to  this  fact,  and  the 
union  of  family  defects  is  seen  not  in  an  arithmetical 
but  geometrical  increase  of  danger.  I  strongly 
maintain  that,  with  marked  insanity  direct  on 
the  one  side,  a  slight,  even  distant,  taint  on  the 
other  side  increases  in  a  very  marked  degree  the 
risk  of  the  children  proving  insane.  The  forms  of 
insanity  transmitted  or  produced  by  such  unions 
will  require  further  consideration ;  but  I  may  say 
that  moral  defects,  so-called  criminality,  and  forms 
of  weak-mindedness,  are  very  common  as  the  result 
of  such  marriages.  Besides  direct  inheritance  of  in- 
sanity, the  offspring  of  [nervous,  hysterical,  unstable, 
or  degenerate  parents  are  proved  to  inherit  nervous 
instability,  and  this  is  most  clearly  seen  in  cases 
where  two  near  relations  of  nervous,  but  not  insane 
stock,  marry.  I  have  seen  such  parents  produce 
whole  families  of  idiots  and  weak-minded  children. 

If,  again,  we  have  insanity  on  one  side,  and  age, 
physical  weakness,  or  some  form  of  degenerative 
disease,  such  as  phthisis,  on  the  other  side,  the  risk  of 
insanity  in  the  offspring  is  increased. 

Besides  the  above,  there  are  cases  in  which  the 
insanity  is  due  to  inheritance,  though  not  of  ordi- 
nary nervous  disease ;  and  we  are  not  yet  in  a  posi- 
tion to  explain  its  action.  Certain  temperaments 
in  the  parents  jDroduce  insane  children,  and  I  have 
known  a  whole  family  of  lunatics,  the  offspring  of 
non-neurotic  parents.  This  is  merely  a  statement 
of  the  fact  that  at  present  we  do  not  know  the  first 


32         Insanity  and  Allied  Neuroses.   [Chap.  iii. 

cause  of  insanity.  From  some  cases  I  have  seen  I 
believe  that  injuries  or  degenerative  changes  in  the 
brain  of  a  parent  may  lead  to  insanity  in  the 
children.  And  here,  again,  the  nearer  the  begetting 
is  to  the  injury  the  more  the  danger.  It  is  in  this 
way,  I  believe,  that  the  children  of  general  paralytics 
may  inherit  ordinary  insanity  if  begotten  after  the 
disease  has  fairly  begun. 

Besides  the  effects  of  msanity  in  the  parents  s^nd 
their  forefathers,  and  in  brothers  and  sisters,  we  must 
consider  cousins  and  second  cousins,  as  this  at  least 
gives  evidence  of  nervous  stock.  It  is  sometimes 
important  to  discover  in  brothers  and  sisters  other 
neuroses ;  one  brother  may  be  an  idiot,  another  epi- 
leptic, and  a  third  suffering  from  ordinary  insanity. 
No  general  law,  however,  has  been  discovered  ex- 
plaining why  one  suffers  from  one  form  of  neurosis, 
and  another  from  some  other  form  ;  the  cliief  inference 
would  be,  that  in  a  family  where  hysteria,  idiocy, 
epilepsy,  and  insanity  occur,  the  parents,  one  or  both, 
are  of  highly  unstable  nervous  systems. 

Occupation. — Under  the  head  of  education  I 
spoke  of  occiq^ation  and  social  positiooi  in  their  relation- 
ship to  the  causation  of  insanity.  And  I  pointed  out 
that  just  as  many  educated  as  ignorant  were  found  to 
suffer  mentally.  Neither  riches  nor  poverty  prevent 
persons  becoming  deranged.  The  millionaire  and  the 
pauper  may  alike  be  mad.  Though,  as  I  shall  show, 
riches  do  not  prevent  the  malady,  yet  the  care  and 
treatment  is  naturally  affected  by  the  possession  of 
wealth.  The  consequence  is  that  there  is  an  appearance 
of  excess  of  insanity  among  the  lower  classes,  simply 
because  the  bread-wiiuier,  being  incapacitated  from 
work,  must  necessarily  be  removed  from  his  home, 
whereupon  his  absence  not  only  deprives  his  family 
of  his  earnings,  but  also  compels  one  or  more  to  look 
after  him  instead  of  adding  to  the  common  store.     The 


Chap.  III.]        Precarious  Occupations.  33 

liberty  of  the  subject  depends,  after  all,  to  a  certain 
extent,  upon  the  length  of  the  purse.  The  weak- 
minded  rich  man  can  be  kept  among  his  friends  by 
the  aid  of  servants  and  attendants,  but  the  poor  man 
is  sent  to  the  workhouse  infirmary  or  to  the 
asylum.  Certain  occupations  seem  more  favourable 
for  the  development  of  mental  disorders  than  others, 
and  my  own  impression  is  that  certain  ijrecarious 
occiqmtiojis,  at  all  events  recently,  have  played  an 
important  part  in  the  production  of  insanit}'.  Thus  I 
refer  to  the  question  of  agricultural  depression,  in 
considering  which  question  it  will  be  well,  however, 
to  guard  against  possible  sources  of  error.  But  the 
fact  most  certainly  is,  that  a  larger  proportion  of  small 
farmers  have  been  admitted  to  Bethlem  durinsf  the 
last  few  years  than  formeiiy.  One  source  of  fallacy 
may  be  that  owing  to  money  losses  they  cannot  be 
paid  for  by  their  friends  in  private  asylums,  and  there- 
fore more  of  them  have  been  sent  as  free  patients. 
But  notwithstanding  this  possibility  of  error,  the  pre- 
carious conditions  of  the  farmer's  life  seem  eminently 
those  likely  to  cause  a  mental  break-down.  Insanity 
is  comparatively  rarely  produced  by  a  single  shock 
or  emotion.  Just  as  the  stone  is  worn  by  the  con- 
stant dropping,  so  the  mind  is  upset  by  the  recurrences 
of  worry;  and  worry,  not  work,  is  the  cause  of  the 
break-down  of  farmers,  ^o  nmount^'of  foresisfht  or 
industry  will  save  them  from  the  effects  of  disastrous 
years.  And  it  seems  that  the  inability  to  stave  off 
misfortune  has  a  particularly  depressing  effect. 

There  are  many  other  occupations  which  are  suffi- 
ciently exhausting,  or  subject  to  recurring  annoy- 
ances. Speculative  businesses  belong  to  this  class. 
And  in  referring  to  general  paralysis  I  shall  have  to 
speak  of  the  mode  of  life  followed  by  speculators 
as  one  tending,  in  my  belief,  to  the  development  of 
this  form  of  mental  disease, 
r^l4 


34        Insanity  and  Allied  Neuroses,   [Chap.  iii. 

In  Betlilem  we  have  a  very  large  number  of 
governesses.  But  here,  again,  the  fact  must  be  taken 
into  consideration  that,  just  as  the  younger  men,  who 
are  struggling  from  the  lower  ranks  of  the 
artisan  into  the  higher  social  ranks,  strive  first  to 
become  clerks,  so  girls  of  the  same  station  endeavour 
to  become  governesses.  And  if  any  special  ability, 
such  particularly  as  that  for  music,  is  exhibited,  they 
are  forced  and  cultivated  along  that  special  line  at 
the  expense  of  their  general  health  and  mental 
balance.  To  my  mind,  the  governess's  life  is  a  very 
good  example  of  the  j)redisposing  causes  of  insanity, 
as  seen  in  action.  Thus  we  see  a  girl  of  nervous 
temperament,  with  high  powers  of  receptivity, 
anxious,  self-sacrificing,  and  with  emotional  and 
artistic  feeling,  thoroughly  good  and  hard-working ; 
showing  more  aptitude  than  her  sisters  for  music, 
she  is  encoui'aged  to  spend  many  hours  of  a  day 
in  practising  the  piano  (I  have  known  such  a  one 
practise  eight  or  ten  hours  a  day  regularly  besides 
occupying  her  time  with  other  matters) ;  and  after 
years  of  home  practice  she  is  taught,  at  considerable 
sacrifice  to  her  pai"ents,  by  some  leading  master,  and 
she  overstrains  herself  in  her  endeavour  to  make  the 
most  of  the  advantages  which  she  was  constantly 
told  she  enjoyed.  In  this  way  her  young  growing 
life  suffers  ;  dyspepsia,  constipation,  and  sleeplessness 
come  early;  uneasiness  occurs  at  the  top  of  the 
head ;  menstrual  irregularity  shows  itself,  at  times 
there  being  profuse  exliaustmg  menorrhagia,  at  others, 
painful  scanty  flow.  In  tliis  unstable  condition  she 
obtains  some  engagement,  or,  more  disastrously,  I 
would  say,  a  situation.  Here  she  is  better  fed,  and 
has  regular  hours ;  but,  on  the  other  hand,  there  are 
no  means  of  drawing  herself  out  of  herself.  The 
child,  or  children,  are  more  or  less  trying  to  her 
temper,  and  she,  the  enthusiast,  is  hourly  annoyed  by 


Chap.  III.]         Effect  of  Occupations.  35 

the  utter  lack  of  interest  exhibited  by  her  pupils. 
She  often  has  no  companions  of  her  own  age  and 
station,  the  heads  of  the  household  look  down  upon 
her  as  belonging  to  an  inferior  grade,  and  her  own 
education  and  position  prevent  her  from  associating 
with  the  domestic  servants.  In  this  manner  she 
becomes  only  one  degree  better  than  the  prisoner  in 
solitary  confinement.  She  is  thrown  into  a  purely 
subjective  life,  building  castles  in  the  air,  dreaming 
what  would  be,  or  might  have  been,  if  only  intellect, 
the  crown  of  man,  had  its  proper  sway,  till  at  last  the 
castles  in  the  air  become  to  her  no  longer  fairy  ideas, 
but  actual  realities.  She  thinks  herself  wedded  to  some 
wealthy  nobleman ;  or,  on  the  other  hand,  she  may  de- 
velop ideas  of  suspicion,  and  fancy  that  every  person 
about  her  is  wishing  to  take  from  her  her  only  posses- 
sion, her  virtue.  It  is  also  worthy  of  consideration 
that  many  who  lead  the  life  of  governesses  have  been 
compelled  to  do  so  by  some  domestic  misfortune  which 
has  suddenly  compelled  them  to  turn  their  education 
to  account,  as  being  the  only  sure  source  of  livelihood 
enabling  them  to  preserve  the  vestiges  of  their  former 
social  position.  In  such  cases  as  these,  in  addition  to 
the  perplexities  and  mortifications  of  their  un- 
accustomed life  of  dependence,  there  would  be  a 
previously  established  predisposing  cause. 

From  the  above  we  can  see  how  a  governess's 
occupation  may  act  as  an  important  factor  in  the 
development  of  insanity.  Beggars  are  said  to  be 
remarkably  free  from  insanity.  That  may  be  true  in 
England,  but  on  the  Continent  it  seems  to  me  that 
insanity  creates  many  successful  mendicants.  Prosti- 
tutes are  said  also  to  be  specially  predisposed  to 
insanity,  and  I  am  not  surprised  that  it  should  be  so. 
In  early  life  (for  very  commonly  they  commence 
their  vicious  career  as  mere  children,  and  have,  like 
the   habitual   drunkard,    in   many   cases    a    directly 


36         Insanity  and  Allied  Neuroses.   [Chap.  in. 

vicious  inheritance),  tliey  are  driven  not  only  to 
gross  sexual  excess,  but  with  it  they  take  to  drink, 
irregularity  of  hours,  and  are  exposed  to  all  sorts  of 
risks  of  bodily  disease,  general  and  local.  Thus  a 
young  unstable  woman,  indulging  in  excess  and 
exposed  to  disease,  breaks  down. 

Reference  has  been  made  to  the  influence  of  con- 
finement on  persons  (more  especially  of  solitary  con- 
finement) in  the  production  of  insanity.  But  at 
present  I  need  only  repeat  the  statement  that  the 
criminal  classes  contain  a  large  number  of  people 
with  insane  inheritance,  who  are  from  birth  predis- 
posed to  insanity,  persons  who  are  already  on  the 
confines  of  insanity,  and  who  merely  require  some 
slight  alteration  in  their  health  and  surroundings  to 
push  them  over  the  border-line.  Solitary  confinement, 
the  enforcement  of  a  subjective  life,  may  lead  to 
insanity.  The  captive,  having  nothing  to  occupy  his 
attention,  is  pretty  sure  to  develop  castles  in  the  air 
of  one  kind  or  another. 

Among  predisposing  causes  I  would  notice  the 
time  of  the  year,  the  climate,  and  the  like.  In 
Bethlem  for  years  past  we  have  always  received  the 
largest  numbers  of  applications  for  the  admission 
of  acute  cases  in  the  summer ;  and  next  in  frequency, 
early  autumn  seems  the  period  most  associated 
with  these  disturbances.  Although  many  superin- 
tendents have  been  at  considerable  pains  to  trace 
relationships  between  meteorological  changes  and  the 
occurrences  of  attacks  of  insanity,  and  of  epileptic 
fits,  at  present  no  distinct  or  direct  connection 
has  been  made  clear.  I  should  certainly  not  agree 
with  some  writers,  in  saying  that  as  a  rule  attacks 
of  mania  occur  in  winter,  but  would  rather  say 
they  are  more  common  in  summer  and  autumn.  A 
question  that  is  still  repeated,  is,  Has  the  moon  really 
anything  to  do   with  insanity'?      And    sonje  of  our 


Chap.  III.]  Heredity.  37 

asylum  attendants  still  believe  in  the  connection. 
My  opinion  is,  that  many  lunatics  will  remain  quiet 
in  bed  during  darkness,  but  will  be  mischievous  and 
refractory  if  there  is  light  enough. 

Among  special  predisposing"  causes,  here- 
dity stands  first  in  importance.  The  child  carries 
on  from  his  parents  special  qualities  and  disposi- 
tions, and  one  recognises  in  all  races  of  animals, 
and  even  in  the  vegetable  kingdom,  special  qualities 
derivable  from  the  male,  and  others  from  the  female. 
Hitherto,  with  all  our  observations  and  statistics,  we 
have  been  unable  to  foretell  what  would  be  either  the 
sex  or  the  quality  of  the  human  offspring.  We  do 
not  even  know  whether,  in  fact,  a  child  who  resembles 
in  appearance  his  father  is  more  or  less  likely  to 
resemble  him  in  mind.  But  we  do  know  that  quali- 
ties of  mind  and  body  are  transmissible,  for  without 
this  there  would  be  an  end  to  all  trainine*  and  de- 
velopment.  If  the  child  did  not  inherit  the  result  of 
all  that  had  gone  before,  with  additional  power  of 
development  on  his  own  part,  all  social  growth  would 
be  rendered  impossible.  The  torch  of  civilisation  is 
handed  from  father  to  son,  and  as  with  the  idiosyn- 
crasies of  mind,  so  the  very  body  itself  exhibits  well- 
defined  marks  of  its  parentage. 

Dr.  Bucknill  has  thrown  doubts  upon  the  impor- 
tance of  inheritance,  and  has  said,  with  a  certain 
amount  of  appearance  of  reason,  that  if  insanity  be  so 
easily  transmitted  from  parent  to  child,  how  is  it  that 
so  many  in  a  family  escape  %  For  instance,  in  a 
case  in  which  the  plea  of  insanity  is  made  use  of  to 
save  a  man  from  the  gallows,  the  criminal  being  the 
only  one  among  six  children  whose  sanity  is  called 
in  question.  How  is  it  that  we  so  seldom  find  the 
criminal  to  have  insane  brothers  and  sisters,  and  that 
the  expert  is  often  driven  to  seek  for  insanity  among 
the  uncles  or  cousins,  and  considers  himself  specially 


38        Insanity  and  Allied  Neuroses.   [Chap.  iii. 

fortunate  if  he  finds  an  insane  mother  or  father  % 
This  is  true  enough,  yet  no  one  is  surprised  to  hear 
that  in  a  family  of  six  or  eight,  only  one  has  some 
physical  peculiarity,  or  some  mannerism  or  trick 
which  has  been  noted  in  the  father's  or  mother's 
family  for  generations.  We  have  to  remember  that 
the  child  is  not  only  the  offspring  of  his  father  and 
his  mother,  but  he  is  the  last  of  a  long  procession, 
and  that  he  is  the  representative  of  their  many 
peculiarities  and  aptitudes,  and  it  would  be  impossible 
for  him  to  have  them  all,  as  some  would  be  contra- 
dictories. 

A  good  example  may  be  seen  by  the  presence  of 
an  extra  finger  or  thumb.  This  peculiarity  may  run 
through  several  generations.  But  it  only  selects  a 
few  individuals.  Yet,  surely,  no  one  would  doubt 
the  importance  of  its  recurrence  as  evidence  of  family 
peculiarity.  Other  peculiarities,  bodily  and  mental, 
are  strikingly  inherited,  some  of  them  clinging  to  the 
male  side,  and  others  to  the  female  side.  Thus 
hsemophilia  will  pass  from  male  to  male  in  a  long 
series,  missing  the  females  altogether.  This  is  a  good 
example,  also,  of  another  peculiarity  of  inheritance, 
which  is  seen  among  the  insane,  the  transmission  of 
a  tendency  without  its  development  in  the  person 
transmitting.  Thus,  in  hsemophilia,  a  father  may 
beget  a  daughter  who  has  no  tendency  to  bleeding, 
but  she  has  sons  who  are  bleeders.  The  insane 
parent  may  beget  a  child  without  any  insanity,  but 
the  next  generation  may  develop  it  to  its  full  extent. 

Insanity,  again,  has  the  peculiarity  of  having 
many  other  correspondencies  and  accompanying 
attributes,  so  that,  being  taken  as  the  supreme  degree 
of  nervous  disorder,  it  may  be  represented  in  other 
terms  by  epilepsy,  hysteria,  hypochondriasis,  vicious 
or  criminal  tendencies,  or  even  painful  nervous  dis- 
orders such  as  neuralgia, 


Chap.  111.]  Heredity.  39 

Insanity  may  be  transmitted  direct  as  far  as  kind 
goes,  so  that  the  hyjDochondriacal  parent  may  have 
a  hypochondriacal  son ;  or  the  inheritance  may  be 
altered  in  form,  the  maniacal  parent  having  a  melan- 
cholic or  epileptic  child. 

One  of  the  phenomena  of  inheritance  seems  to 
be  a  tendency  that  may  be  transmitted  to  break  down 
under  similar  conditions,  such  as  age  or  child-birth. 
Thus  I  have  known  several  instances  in  which  the 
family  inheritance  was  a  tendency  to  pass  into  a  state 
of  weak-mindedness  with  melancholy  at  a  certain 
period  of  life.  The  weak  spot  in  the  family  was  the 
nervous  system,  and  they  began  to  die  from  above 
downward.  Perhaps  the  suicidal  tendency  is  one 
which  appears  to  be  most  directly  and  distinctly 
transmitted,  and  I  shall  have  occasion  elsewhere  to 
narrate  cases  in  which  one  member  after  another  of  a 
family  has  committed  suicide,  although  under  dis- 
similar conditions  of  climate  and  social  surroundings  ; 
though  in  fact  separated  by  continents,  the  same  family 
tendency  to  self-destruction,  the  same  inability  to  bear 
reverses  philosophically,  the  same  unrestrained  motor 
impulse  to  end  their  troubles  has  manifested  itself. 

Another  form  of  direct  inheritance  is  seen  in  those 
cases  in  which  mother  and  daughter  have  suffered  from 
puerperal  insanity.  But  in  this,  as  in  the  last  case, 
there  is  added  the  direct  tendency  to  dwell  upon  the 
illness,  or  misfortune  of  the  near  relation.  Nothing 
seems  to  make  a  deeper  impression  upon  a  man  than 
the  fact  that  a  brother  or  father  committed  suicide ; 
and  no  impression  seems  so  readily  made  as  in  the 
case  of  a  woman  affected  by  some  disturbance  during 
the  period  of  pregnancy  or  child-birth ;  so  that  the 
conditions  capable  of  direct  transmission  are  not  un- 
complicated examples  of  simple  heredity. 

It  is  rare  to  be  able  to  trace  direct  inheritance  of 
insanity  through  many  generations. 


40         Insanity  and  Allied  N'eu roses.   [Chap.  ill. 

The  tendency  of  disease  is  to  death  or  destruction. 
There  may  be  a  vis  medicatrix  naturce  in  acute  diseases, 
but  it  seems  to  me  that  in  insanity  there  is  compara- 
tively little  tendency  to  direct  correction  of  faults  of 
birth. 

The  person  with  weak  nervous  system  is  likely 
to  beget  children  with  weak  nervous  systems  also. 
This  tendency,  then,  if  present  on  both  sides  of  the 
family  is  likely  to  produce  examples  of  extreme  mental 
weakness,  such  as  is  seen  in  idiots.  The  tendency  to 
inheritance  of  insanity  depends,  to  a  very  great  extent, 
upon  the  bodily  as  well  as  the  mental  condition  of  the 
parent.  In  this  manner  one  has  frequently  seen  cases 
in  which  an  insane  parent  has  begotten,  or  developed, 
sane  children  in  intervals  between  the  attack  of  in- 
sanity ;  but  if  the  father  happens  to  beget  a  child 
about  the  period  of  an  attack,  the  chances  of  the 
sanity  of  the  child  are  small.  The  same  holds  good  in 
reference  to  the  mother. 

Another  mode  of  starting  neurotic  inheritance  by 
heredity  is  from  injuries  to  the  head,  or  mental  dis- 
order in  a  parent,  associated  with  physical  illness.  I 
have  notes  of  insanity  occurring  in  the  offspring  after 
injuries  to  the  head  of  the  father ;  and  in  other  cases 
I  have  met  with  post-febrile  insanity  in  the  father 
giving  rise  to  weak  -  mindedness  or  liability  to 
insanity  in  the  children  begotten  about  the  time  of 
the  father's  illness.  Undoubtedly  some  forms  of 
insanity  are  much  more  readily  transmitted  than 
others,  and  it  is  of  the  utmost  importance  that  we 
should  be  in  a  position  dogmatically  to  say  there  is, 
or  there  is  not,  danger  to  the  children  of  such  and 
such  parents.  The  advice  of  the  consulting  physician 
is  frequently  sought  as  to  the  propriety  of  certain 
couples  marrying ;  and  although  the  advice  given  is 
often  disregarded,  the  question  is  sufficiently  important 
to  be  considered  carefully.     I    am    in   the  habit   of 


Chap.  III.]    Constitution  and  Temperament.       41 

saying  that  general  paralysis  of  tlie  insane  is  not  to  be 
considered  as  an  ordinary  nervous  disorder ;  that  it 
does  not  occur  directly  as  the  inheritance  of  ordinary 
insanity;  at  least,  that  it  very  frequently  has  no 
connection  whatever  with  ordinary  forms  of  mental 
derangement.  On  the  other  hand,  the  children  of 
general  paralytics,  especially  those  who  may  have 
been  begotten  after  the  first  well-marked  symptoms 
of  general  paralysis  have  developed  themselves,  are 
likely  to  be  idiotic,  or,  if  they  are  sane  as  children,  they 
may  later  in  life  develop  ordinary  neuroses.  I  have 
seen  one  patient  in  Bethlem  suffering  from  melan- 
cholia, whose  father,  to  my  knowledge,  died  of  general 
paralysis  ;  and  I  have  been  consulted  about  the  child 
of  a  medical  man  who  has  been  weak-minded  from 
birth,  she  having  been  begotten  after  her  father  pre- 
sented well-marked  symptoms  of  general  paralysis. 

These  facts  of  inheritance  show  that  the  damaged 
brain,  whether  damaged  by  injury  or  decay,  may 
give  rise  to  states  and  conditions  leading  to  mental 
degeneration  or  disorder  in  the  offspring. 

Constitution  and  temperament. — My  ex- 
perience leads  me  to  believe  there  is  a  distinctly  melan- 
cholic temperament,  but  I  am  not  equally  prepared  to 
say  that  there  is  a  special  type  constitutionally  pre- 
disposed to  attacks  of  acute  mania.  The  term  melan- 
cholia, derived  from  the  old-world  belief  that  black 
bile  had  much  to  do  with  mental  depression,  is  so  far 
borne  out  by  experience  that  the  dark-complexioned 
and  dark-haired  melancholies  are  very  largely  in  excess 
of  the  fair  persons  suffering  from  mental  depression  j 
this  notwithstanding  the  fact  that  at  least  an  equal 
number  of  people  belonging  to  the  middle  classes  in 
England  are  fair,  and  with  light  hair.  It  seems  as 
though  there  were  truth  in  the  old  idea  that  per- 
sons with  dark  complexions  were  likely  to  have  slug- 
gish function,-;   and  tendencies  to  look  on  the  gloomy 


42         Insanity  and  Allied  Neuroses.   [Chap.  iii, 

side  of  things.  I  shall  have  to  point  out  that  insanity 
is  associated  with  various  other  forms  of  constitution, 
and  that  no  temperament  is  free  :  for  though  diseases 
like  phthisis  give  a  special  colouring  to  mental  dis- 
order ;  though  gout,  with  its  loaded  and  impeded  cir- 
culation, may  impress  a  s^Decial  character  on  mental 
trouble,  yet,  as  "  man  is  born  to  trouble,  as  the  sparks 
fly  upward,"  so  it  would  be  unreasonable  to  expect  all 
insane  people  to  possess  specially  insane  temperaments, 
or  that  all  should  break  down  from  one  cause.  The 
stress  of  life  may  fall  most  heavily  along  the  weakest 
lines  and  may  cause  break-down ;  whereas  troubles  of 
another  order  might,  in  the  same  case,  fail  to  cause  a 
mental  decline.  Those  unused  to  insane  patients  are 
constantly  on  the  look  out  in  an  asylum  for  peculi- 
arities in  aspect,  or  marked  strangeness  in  the  eyes  of 
the  persons  they  meet.  But  as  no  one  expects  to  meet 
the  poet  in  society  with  his  "  eyes  in  a  fine  frenzy  rol- 
ling," so  no  one  should  expect  always  to  see  the  lunatic 
with  a  mad  aspect.  It,  however,  often  strikes  an 
observer,  that  among  chronically  insane  patients  there 
does  seem  to  be  a  development  of  a  special  type  of 
feature,  and  that  this  type  is  distinctly  a  low  one. 
That  just  as  it  is  rare  in  an  idiot  asylum  to  see  a 
beautiful  and  well-formed  child  (although  not  an  im- 
possibility), so  in  a  lunatic  asylum  I  would  say  it 
is  seldom  one  meets  with  striking  j)hysical  beauty. 
The  transmission  of  insanity,  as  I  said  before,  tends 
gradually  to  the  abasement  and  ultimate  extinction 
of  the  race.  Degeneracy  in  nature  is  naturally  in 
opposition  to  beauty  and  well-being.  If  an  insane 
temperament  be  allowed  to  exist,  it  is  that  which 
is  represented  by  what  is  ordinarily  called  the  ner- 
vous temperament,  and  in  certain  families  we  meet 
with  all  the  varieties  of  neurosis  in  one  member  or 
another.  Such  a  family  may  be  said  to  have  the 
nervous   constitution,  and    may   be   looked   upon   as 


Chap.  III.]     The  Nervous  Constitution:  43 

nearly  related  to  the  insane,  yet  tliere  may  be  nothing 
physical  which  can  be  pointed  to  as  characteristic 
or  typical. 

Besides  direct  inheritance,  the  crossing  of  mem- 
bers of  consumptive  families  with  members  of  other 
families  suffering  from  some  other  forms  of  degenera- 
tion seems,  in  my  experience,  to  produce  the  nervous 
constitution  which  shows  itself  in  a  tendency  to 
nervous  break-down.  It  is  often  difficult  to  drav/ 
any  fine  line  between  predisposing  and  exciting  causes, 
but  in  some  the  distinction  is  simple  and  straight- 
forward. A  person  having  an  insane  parentage 
gets  into  feeble  health,  and  is  thereby  predisposed 
to  break  down,  by  inheritance  primarily,  by  physical 
weakness  secondarily.  He  gets  hold  of  some  quack 
publication,  or  falls  under  the  influence  of  some 
emotional  teacher,  and  thus  the  spark  is  applied  to 
the  explosive,  and  the  result  is  the  outbreak  ;  or  a 
lad,  with  some  strongly  insane  inheritance  through 
his  mother,  receives  a  blow  on  the  head,  and  he 
becomes  maniacal.  A  man  acquires  the  habit  of 
gambling,  drinks  and  smokes  to  excess,  and  leads 
a  life  of  recklessness,  during  which  he  receives  an 
injury  to  his  head,  and  this  is  followed  by  a  slight 
attack  of  deliriuim  tremens,  resulting  in  an  outburst 
of  insanity.  In  this  case,  drink  was  at  work  impair- 
ing the  nourishment  of  the  nervous  tissues,  lowering 
the  vitality  of  the  man,  rendering  him  less  stable,  so 
that  a  slight  disturbance  of  his  nervous  system,  pre- 
viously undermined  by  alcohol,  led  easily  enough  to  a 
more  chronic  perversion  of  mind.  In  the  last  two 
cases,  the  exciting  causes  Avere  both  blows  on  the 
head,  but  the  predisposing  causes  differed  entirely. 
And  my  chief  objection  to  any  tabulated  returns  of 
the  causation  of  insanity,  as  seen  in  asylum  patients, 
is  that  it  is  extremely  uncommon  to  find  a  simple, 
straightforward  case  in  which  there  has  been  but  one 


44         Insanity  and  Allied  Neuroses.   [Chap,  in 

predisposing  and  one  exciting  cause.  As  "  the  last 
straw  breaks  the  camel's  loack,"  so  the  continuance  of 
one  vicious  habit,  indulged  in  for  a  sufficient  length 
of  time,  may  lead  to  mental  derangement,  the  same 
cause  being  both  the  predisposing  and  exciting  agent. 

Exciting  causes  may,  like  predisposing  ones, 
be  either  moral  or  physical.  Mental  disorder 
may  be  equally  produced  by  a  mental  shock  or  a 
blow  on  the  head.  The  exciting  cause  may  be 
uniform  or  multiform  in  nature.  It  may  take  the 
form  of  undue  excitement  or  of  want  of  fellowship. 
Solitude  or  joy,  love  or  hate,  may  be  at  times  suffi.- 
cient  to  cause  a  mental  upset.  To  sum  up  this  part 
of  my  subject,  I  would  say  that  one  cause  may  be 
predisposing  alone,  or  predisposing  and  exciting,  or 
exciting  alone  ;  that  there  are  causes  which  may  be 
considered  as  complex  or  mixed,  and  that  some  causes 
act  both  physically  and  morally. 

Moral  and  pliysical  cauisatioii. — Moral. — 
I  shall  briefly  refer  to  each  cause  given  under  this 
head.  Domestic  trouble  is  the  first  moral  cause,  and 
includes  the  loss  of  relatives  and  friends.  Yearly 
many  patients  are  admitted  into  asylums  with  a 
history  of  domestic  trouble  as  the  alleged  cause 
of  their  insanity.  This  is  one  of  the  constant 
causes ;  that  is,  it  is  one  of  the  causes  that  act 
from  day  to  day  and  from  hour  to  hour.  It  is 
not  like  the  sudden  shock  or  fright,  but  it  is  the 
condition  which  is  associated  with  a  thousand  and 
one  other  slight  ailments.  Domestic  trouble,  so 
called,  is  one  of  the  most  far-reaching  of  morbid 
actions.  The  appetite  is  impaired,  digestion  fails, 
sleep  is  disturbed,  respiration  is  no  longer  regular 
and  quiet ;  the  pulse  often  becomes  hard,  the  tension 
being  high.  The  more  the  development  of  such  con- 
ditions is  watched,  the  more  one  is  convinced  that 
grave  general  nutritional  changes  are  going  on.      I  am 


Chap.  III.]  Domestic  Trouble.  45 

convinced,  with  Dr.  Sutton  of  the  London  Hospital, 
that  this  condition  may  readily  pass  either  into  Bright's 
disease  or  insanity,  and  I  would  look  upon  the  degree 
of  tension  in  the  whole  body  as  the  one  dangerous 
element  to  be  considered.  Grief,  as  a  part  of 
domestic  worry,  is  also  of  great  impoi'tance.  Good 
examples  of  what  is  meant  by  the  effect  of  grief  in 
producing  insanity  are  frequently  seen  in  the  wards 
of  Bethlem,  where  a  woman  has  watched  and 
nursed  for  months  together,  with  very  little  rest  by 
day  or  night,  some  near  relative  whose  nervous  and 
exacting  temperament  has  tasked  the  nurse  to  the 
utmost.  Such  a  person,  after  the  excitement  of 
nursing  and  the  burial  of  the  relative,  sinks  into  a 
condition  of  extreme  weakness,  and,  as  a  result, 
conjures  up  all  sorts  of  imaginary  crimes  that  she  has 
committed,  often  thinking  she  has  neglected,  or  even 
killed,  the  person  for  whom  she  was  sacrificing  so 
much.  Grief  or  shock  at  the  loss  of  relatives, 
though  it  may  cause  insanity,  does  not  necessarily  pro- 
duce melancholic  symptoms.  At  first  sight,  one  would 
think  that  the  loss  of  a  near  relation  would  produce 
mental  depression,  but  such  an  example  as  the  follow- 
ing will  show  that  mental  disorder  may  be  produced 
by  painful  shock  which  shows  itself  as  acute  mania. 
A  young  woman,  who  had  been  engaged  to  be  married 
to  a  man  who  had  emigrated  to  one  of  the  colonies  with 
a  view  of  making  his  fortune,  lost  sight  of  her  lover  for 
eight  or  nine  years,  and  supposed  herself  deserted  by 
him.  She  unexpectedly  received  a  letter  from  him, 
asking  if  she  were  still  free  and  willing  to  accept  him, 
as  he  was  returning  home.  She  readily  accepted  him, 
and  spent  all  her  liard-earned  money  in  providing  a 
trousseau  suitable  for  the  bride  of  a  wealthy  man. 
He  returned,  and  she  was  married  to  him,  though  she 
was  somewhat  surprised  to  find  he  was  physically  a 
wreck,  and  had  not  the  appearance  of  wealth.     On 


46         Insanity  and  Allied  Neuroses.   [Chap.  iii. 

the  ninth  day  from  her  wedding  she  awoke  to  find 
her  husband  dead  by  her  side.  The  seeds  of  disease 
sown  in  the  colony  had  borne  their  fruit  in  his  sudden 
death.  The  result  of  this  shock  (for  she  found  her- 
self now  penniless  and  a  widow)  was  an  attack  of 
acute  mania  which  lasted  several  months.  Other 
similar  cases  of  grief  producing  acute  mania  are 
sufiiciently  common.  Grief  may  produce  a  depression 
passing  into  melancholia,  or  the  blow  may  be  a  stun- 
ning one.  Thus,  a  person  nursing  most  devotedly  for 
months  her  paralysed  husband,  broke  down,  and, 
after  a  slight  fit  of  unconsciousness,  lost  her 
memory  of  all  recent  events,  and  is  now  practically 
incurably  weak-minded.  To  sum  up,  domestic  worry 
may,  and  undoubtedly  does,  produce  insanity,  both  in 
those  with  an  hereditary  predisposition  and  in  those 
without.  The  domestic  worry  acts  on  the  body  and 
on  the  mind ;  in  some  the  body  sufiering  chiefly,  and 
the  patient  dying  of  kidney  disease  or  allied  diseases ; 
or,  where  the  mental  symptoms  predominate,  the 
patient  becomes  melancholic,  maniacal,  or  weak- 
minded,  the  melancholy  often  gathering  with  a  dream- 
like vagueness  of  imagery  about  the  relative  who  has 
died. 

Adverse  circiiiiistaiices  (including  business 
anxieties  and  ^^ecuniary  difficulties).-— TYvis  variety  of 
cause  acts  mostly  on  men,  while  domestic  trouble,  etc., 
falls  most  heavily  on  women.  This  cause  also  rarely 
acts  suddenly,  but  is  long  preparing  for  the  disaster 
by  petty  worries,  anxieties,  loss  in  position  and  social 
regard,  which  may  be  often  followed  later  by  penury, 
starvation,  or  over-stimulation  induced  by  anxiety  and 
sleeplessness.  Later  I  shall  refer  to  the  frequency 
with  which  this  cause  is  given  for  general  paralysis. 
Every  year  patients  are  admitted  who  have  sustained 
severe  money  losses,  and  amongst  them  are  cases  in 
which  distress  to  themselves  and  faniilies  has   been 


Cbap.  III.]  Nervous  Axxiety.  47 

suddenly  produced.  It  must,  however,  be  borne  in 
mind  that  money  losses  are  not  uncommonly  asso- 
ciated with  early  mental  disorder  as  being  an  effect 
of  the  latter  rather  than  its  cause.  Now-a-days,  the 
speculative  man  who,  through  loss  of  memory  or 
slight  impairment  of  judgment  begins  to  lose  his 
business,  is  often  likely  to  end  in  ruin.  It  is  a  very 
important  symptom,  if  it  can  be  clearly  shown  that  a 
business  man  is  losing  his  aptitude  for  accounts.  I 
have  known  such  a  person  exhibit  a  failure  in  his 
rubber  of  whist,  this  being  the  earliest  symptom  of  a 
disorder  which  cost  him  many  thousands  of  pounds. 
In  such  a  case  the  money  loss  is  the  result,  not  the 
cause  of  the  disorder.  Special  conditions,  such  as 
those  of  the  farming  interest  and  the  landed  pro- 
prietor in  anxious  times,  undoubtedly  cause  dis- 
order ending  in  insanity,  and  it  is  but  natural  that 
this  should  be  so.  I  must  repeat  that  mental  disorder 
is  in  most  cases  a  morbid  growth,  and  that  worry  and 
anxiety,  if  constantly  straining  the  nervous  energies, 
are  pretty  sure  to  cause  a  break  down  in  certain 
people.  Pecuniary  anxieties,  of  course,  may  be  asso- 
ciated with  success  as  well  as  with  failure,  and  although, 
as  has  been  repeatedly  noted,  joyous  passions  and 
pleasures  are  less  destructive  than  painful  ones,  yet 
the  anxiety  of  becoming  rich  and  enlarging  the  barns 
and  store-houses  may  produce  a  wear  out.  I  have 
seen  several  cases  in  which  men  of  unbounded  energy 
have  risen  from  the  ranks  by  sheer  force  of  will  and 
work,  men  who  seemed  argus-eyed,  and  able  to  go 
through  the  labours  of  a  Hercules.  But  they  drew 
upon  their  capital  too  heavily,  and  the  end  was  phy- 
sical and  mental  bankruptcy,  though  with  boundless 
wealth, 

To  conclude  this  section,  adverse  circumstances, 
money  losses,  especially  those  associated  with  constant 
anxiety,  tend  to  act   by   depressing   physically  and 


4  8         Insanity  and  Allied  Neuroses.   [Chap.  hi. 

mentally,  and  by  producing  symptoms  similar  to  those 
described  as  the  result  of  domestic  trouble,  lead  to 
insanity. 

Two  points  to  be  noticed  are  that  more  men  than 
women  suffer  from  insa.nity  produced  by  causes  of  this 
nature,  and  that  general  paralysis  of  the  insane  is 
a  common  result. 

Mental  anxiety  and  wos'ry  witli  over- 
work.— This  group  of  causes  acts  both  on  men  and 
women,  and  for  convenience  other  causes  of  worry 
and  anxiety,  such  as  can  scarcely  be  considered  do- 
mestic or  economic,  are  placed  under  this  head. 
Foolish  ambition,  failure,  especially  if  repeated,  the 
striving  to  hold  a  false  position,  the  fact  of  being  out 
of  relationship  to  surromidings  (this  is  seen  in  the 
intellectual  or  social  parvenu),  and  over-work,  are 
the  chief  varieties  that  I  shall  here  consider. 

Ambition  may  be  what  is  teimed  laudable  ambi- 
tion, or  it  may  be  the  striving  for  the  unattainable ; 
and  all  students  of  Faust  must  be  impressed  with  the 
danger  there  is  in  seeking  either  for  satisfaction  in 
the  sensuous  or  in  the  intellectual  alone.  Such  un- 
attainable ambition  leads  to  mental  disturbance.  The 
unfortunate  person  is  always  striving  for  the  stars, 
and  his  mental  attitude  is  well  pourtrayed  in  some  of 
the  weird  sketches  of  William  Blake,  himself  very 
near  insanity.  Ambition  of  this  kind  acts  on  body 
and  mind  alike.  It  occurs  as  a  cause  of  insanity 
mostly  in  young  men ;  and  I  shall  have  to  refer  later 
to  a  special  class  of  youths,  seen  chiefly  at  the  old 
universities,  who,  straining  to  lead  absolutely  pure 
and  unemotional  lives,  ignore  the  fact  that  they  have 
animal  parts  and  animal  passions;  they  do  not  see, 
that  although  control  is  the  highest  thing  to  be 
attained,  suppression  is  impossible,  and  either  too 
much  must  not  be  expected  or  failure  must  be  allowed 
fox\     Men  with  such  ambition  not  unfrequently  pass 


Chap.  III.]  Overwork.  49 

into  a  condition  of  mental  hypochondriasis,  and  unless 
some  rude  social  or  physical  disturbance  recalls  them 
to  their  senses,  they  stand  a  great  chance  of  becoming 
first  insane,  and  later  weak-minded. 

Omr-work  needs  some  consideration,  since  few 
questions  are  asked  more  frequently  of  the  phy- 
sician than  such  as  relate  to  the  influence  of  over- 
work in  the  production  of  insanity.  In  educa- 
tion we  have  seen  that  bad^  ill-directed  teaching- 
may  act  injuriously  upon  the  growing  mind ;  but  1 
give  my  opinion  strongly,  that  with  judicious 
education,  even  when  a  large  number  of  subjects  is 
studied,  no  danger  is  to  be  apprehended.  The  kind  of 
over- work  which  produces  ill  results  is  forced  work  in 
direct  opposition  to  the  tastes  and  aptitudes  of  the 
pupil,  especially  when  this  takes  place  under  bad 
hygienic  conditions,  and  with  the  excitement  and 
pressure  of  impending  examinations  acting  as  a  stimu- 
lus. Good  examples  of  over-work  are,  to  my  mind, 
best  found  in  the  young  governess  and  the  self- 
educated  man.  The  severity  with  which  young  girls 
are  forced  by  injudicious  and  ambitious  parents 
deserves  censure.  A  girl  of  fourteen  or  fifteen  years 
old  is  expected  to  spend  twelve  hours  a  day  in  learn- 
ing languages,  practising  music,  drawing,  and  deport- 
ment ;  and  if  I  have  to  censure  one  part  of  the 
education  more  than  another^  it  is  the  deportment. 
Girls  are  not  j)ermitted  to  exercise  their  limbs  and 
their  chests  with  heart  and  lungs,  but  must,  forsooth, 
use  implements  of  torture  to  keej)  their  shoulders 
straight  and  their  waists  within  the  bounds  which 
nature  intended.  Just  as  the  forced  plant  may  flower 
out  of  season,  so  the  forced  girl  will  become  prema- 
turely a  woman.  The  sexual  instincts  are  developed  at 
the  cost  of  the  already  enfeebled  body,  and  excessive 
or  irregular  and  painful  menstruation  occurs  in  girls 
who  are  ill-fitted  to  bear  any  extra  drain  on  their 
E— 14 


50         Insanity  and  Allied  N'el roses,   [Chap.  iii. 

strength.  Over- work  may  seem  to  be  an  odd  term  to 
give  to  the  combined  causation  of  this  state,  but  if 
such  a  girl  be  not  over-wrought  I  do  not  know 
who  is. 

Another  common  example  of  over-Avork  is  that 
seen  in  the  self-educated  man,  who  so  frequently  has 
an  unbounded  desire  for  knowledge,  but  does  not 
know  how  to  acquire  it.  He  has  a  great  idea  that 
knowledge  of  facts  is  education,  and  looks  with  con- 
tempt upon  the  older  universities  and  schools  as  m.ere 
excuses  for  passing  time  for  the  jeunesse  doree.  He 
cannot  see  that  education  literally  and  really  means 
the  development  of  all  sides  of  the  character,  and 
that  mere  special  culture  will  fail  to  make  a  learned 
man.  The  effects  of  solitary  self-culture  are  worse  if 
begun  after  the  plastic  youthful  nervous  system  has 
taken  its  form,  as  it  is  hard  to  change  its  figure  after 
it  has  once  hardened  into  habit. 

Work  of  a  monotonous  character  is  injurious,  and 
assists  in  producing  mental  disorder.  But  such  work 
is  comparatively  rare.  To  rny  mind,  the  letter-sorter, 
the  proof-reader,  and  persons  employed  to  check  me- 
chanical labour  run  the  greatest  risk  of  breaking  down 
from  this  cause.  A  clerk  or  an  accountant  may  sufier 
from  the  monotony  of  his  work,  but  with  all  its  dry- 
ness it  is  not  so  absolutely  uniform  as  that  of  the  man 
who  sorts  letters,  signals  trains,  or  corrects  proofs 
under  the  pressure  of  time. 

Meligioiis  exciteiiiefiit.— Probably  few  causes 
of  insanity  are  more  frequently  in  the  mouth  of  the 
general  public  than  religious  excitement :  and  yet  the 
experience  of  the  asylum  physician  is  that  religious 
excitement  does  not  produce  any  large  proportion  of 
the  cases  which  come  under  his  observation.  In 
considering  the  effect  of  religious  excitement  in  the 
production  of  insanity,  we  have  to  remember  that 
there  are  several  very  important  sides  to  the  question. 


Chap.  III.]  Religious  Mania.  51 

Firstly,  what  is  meant  by  religious  excitement  % 
Secondly,  is  the  effect  direct  or  indirect  %  and  thirdly, 
what  is  the  nature  of  the  })erson  so  affected  ? 

There  seems  to  be  abroad  a  feeling  that  nearly  all 
insanity  is  the  result  of  drunkenness,  love,  or  religion. 
All  of  these  may,  separately  or  together,  assist  in  the 
production  of  mad  folk.  But  I  think  too  great  atten- 
tion is  j)aid  to  them  as  special  factors  of  the  disorder. 
An  increase  of  insanity  is  sometimes  apparent  after 
religious  revivals  ;  but  it  is  a  question  whether  a  large 
number  of  the  people  who  thus  exhibit  insanity  are 
not  already  prepared  for  the  manifestation  of  insane 
symptoms,  and  whether  religious  excitement  has  only 
acted  in  modifying  or  giving  colour  to  the  insanity. 
In  fact,  religion  has  been  only  the  exciting  cause,  and, 
as  has  already  been  remarked,  it  does  not  follow  that 
the  symptoms  produced  by  religious  excitement  should 
necessarily  be  of  any  particular  religious  type.  When 
people  talk  of  religious  mania,  they  often  confound  two 
things  ;  first,  the  cases  in  which  patients  are  constantly 
speaking  about  religious  matters,  more  especially  those 
who  are  for  ever  repeating  texts,  or  with  hand- 
wringing  and  melancholy  aspect,  are  complaining  that 
their  souls  are  lost ;  and  next,  the  cases  which  appear 
to  have  been  produced  by  some  religious  movement. 
There  is  a  very  great  distinction  to  be  made  between 
the  many  cases  which  exhibit  some  religious  symptoms 
and  the  few  which  are  really  caused  by  religion  itself. 
Just  as  good  education,  even  though  a  great  deal  of 
it  is  forced  upon  the  growing  animal,  rarely  produces 
harm,  so  religion  even  in  excess  need  not  be  the 
simple  cause  of  mental  disturbance. 

It  may  be  well  here  to  point  out  a  reason  for  the 
constant  recurrence  of  religious  ideas  in  the  insane. 
One  of  the  most  marked  characteristics  of  religion  is  its 
mysticism,  its  professed  dealings  with  powers  which 
cannot  be  weighed  and  measured,  and  yet  which  have 


52         Insanity  and  Allied  Neuroses.  [Chap.  iii. 

an  enormous  influence  on  the  well-being  of  the  indi- 
vidual. The  person  passing  from  a  condition  of 
sanity  into  one  of  insanity  goes  through  a  series  of 
indescribable  feelings,  and  he  thinks  his  new  ex- 
periences may  after  all  be  explained  by  the  powers  of 
the  Omnipotent  exercised  over  him.  JReligions  have 
always  dealt  largely  in  explaining  strange  or  unusual 
occurrences,  and  the  same  tendency  is  constantly  met 
with  in  persons  of  unsound  mind.  In  many  cases 
the  patient,  suffering  from  the  earlier  stages  of  melan- 
choly, is  looking  about  for  some  possible  cause  of  his 
misery,  and  having  failed  to  find  in  his  bodily  or 
mental  surroundings  any  satisfactory  explanation  of 
his  feelings,  he  discovers  one  in  some  text  of  Scripture. 
The  religious  side  of  civilised  society  is  an  important 
one,  and  finds  occupation  for  such  a  large  class  of 
men,  and  more  women,  that  it  would  be  strange 
indeed  if  it  did  not  produce  some  special  fruit  when 
the  mind  is  unbalanced.  A  direct  way  in  which 
religious  excitement  acts  is  by  causing  restless  un- 
curbed emotional  excitement,  so  that  the  person 
affected  may  pass  through  a  period  of  religious 
devotion  into  one  of  hysterical  disturbance,  and  this 
may  lead  to  maniacal  fury.  On  the  other  hand, 
religion  may  act  indirectly,  as  we  have  recently  had 
experience  with  the  Salvation.  Army,  to  a  certain  ex- 
tent causing,  but  to  a  much  greater  extent  colouring, 
the  disease.  Thus  an  old  clergyman,  whose  arteries 
are  getting  rigid  and  who  is  suffering  from  dyspepsia 
and  constipation,  becomes  sleejDless  and  worried,  and 
fancies  that  he  is  on  the  brink  of  ruin,  or  that  his 
children  are  in  distress  ;  next  he  feels  he  has  not  been 
a  good  father  or  a  faithful  pastor.  From  this  state  it 
is  but  a  slight  step  to  the  belief  that  he  is  utterly 
unworthy,  and  that  while  he  has  been  preaching  to 
others  he  himself  will  be  a  castaway.  Similar  cases 
to  this  are  common  enough,  and  I  believe  the  majority 


Chap.  III.]  Religious  Mania.  k,i 

of  them  occur  with  those  who  are  the  most  earnest 
of  all  in  their  profession,  especially  if  with  earnest- 
ness there  is  but  little  culture  of  the  broader  kind. 

Among  patients  who  are  upset  by  religious  excite- 
ment I  distinguish  two  classes,  the  one  the  young  and 
emotional,  the  other  the  old  or  degenerating,  who 
are  frequently  emotional  too.  In  connection  with  the 
first  class  we  have  to  bear  in  mind  the  fact  that 
religion  is  very  closely  allied  to  love,  and  that  the 
love  of  woman  and  the  worship  of  God  are  con- 
stantly sources  of  trouble  in  unstable  youth.  And  it 
is  interesting  to  note  the  frequency  with  which  these 
two  deep  feelings  are  associated.  In  the  second  class, 
as  we  have  said,  the  older  cases  occur,  and  these 
are  chiefly  characterised  by  mental  depression  with 
feelings  of  unworthiness,  and  with  ideas  of  not 
having  done  their  duty,  or  having  committed  that 
most  wonderful  of  all  faults,  ^'the  unpardonable  sin." 
In  these  cases,  too,  there  may  be  sexual  perversions 
as  well,  so  that  one  patient  will  consider  she  has  com- 
mitted the  unpardonable  sin  in  allowing  marital 
congress,  while  another  thinks  she  has  failed  by 
denying  it,  thus  driving  her  husband  to  sin.  The 
religious  and  sexual  sides  of  man's  nature  are  both 
closely  connected  with  the  emotional  development  and 
are  connected  with  his  organic  nature.  I  have  often 
been  astonished  to  find  that  miserable  patients  in  a 
lunatic  asylum  were  still  indulging  in  some  form  of 
sexual  excess. 

To  sum  up,  religious  excitement  may  produce  some 
insanity  in  unhinging  those  among  the  young,  espe- 
cially among  the  young  nervous  females  of  a  society 
over  which  an  emotional  religious  wave  passes.  As 
a  rule,  however,  religious  insanity,  so  called,  is  the 
symptom,  not  the  cause  of  the  disorder. 

liOve  (including  seduction). — I  naturally  pass 
from  the  consideration  of  insanity  that  is  produced 


54         Insanity  and  Allied  Neuroses.    [Chap.  iii. 

by  religious  disturbance  to  that  caused  by  love.  And 
here  I  shall  consider  love  in  the  more  spiritual  sense, 
having  in  the  next  section,  under  physical  causes,  to 
refer  to  sexual  excesses  of  various  kinds. 

Love  has  a  powerful  exercise  in  stimulating  to 
bodily  and  mental  action.  Desire  is  one  of  the 
strongest  of  animal  passions.  The  wild  animal,  such 
as  a  stag,  who  is  docile  or  timid  to  a  degree,  will, 
when  that  causa  teterrima  belli,  love,  enters  in,  become 
a  furious  and  dangerous  antagonist.  Education  and 
the  restrictions  of  society  have  done  much  to  suppress 
the  appearances  of  emotion,  and  have  controlled  most 
markedly  the  exhibitions  of  sexual  longing.  But  the 
root  of  the  evil  lies  deeper,  and  as  soon  as  self-control 
is  lost,  one  sees  the  passions  manifested  in  all  their 
naked  truth.  Love,  under  these  circumstances,  will 
have  to  be  looked  upon  as  one  of  the  causes,  and  also 
of  the  symptoms,  of  mental  disorder.  Generally,  dis- 
appointment, unrequited  affection,  or  extinguished 
passion  are  the  chief  causes,  so  that  it  may  be  ac- 
cepted as  extremely  rare  for  disturbance  to  arise  from 
the  successful  pursuit  of  love.  As  with  the  other 
causes,  there  must  be  fretting  or  jarring  of  the  wheels 
of  the  machine  to  cause  disaster.  The  mere  healthy 
fulfilment  of  functions  is  not  likely  to  produce  disease. 
The  persons  most  likely  to  break  down  from  disap- 
pointed affections  are  women  ;  and  the  danger  in- 
creases with  age  up  to  a  certain  limit,  so  that  it 
would  be  considered  a  much  more  serious  thing  for 
a  woman  of  thirty  to  be  cast  off  by  her  lover  than 
for  one  of  twenty.  The  consideration,  however,  of 
nervous  inheritance  would  have  something  to  do  with 
the  prospect,  and  any  other  cause  of  special  bodily 
deterioration  will  have  also  to  be  noted.  Thus,  as 
may  readily  be  expected,  seduction,  in  addition  to 
cruel  desertion,  will  greatly  increase  the  probability  of 
a  mental  upset. 


Chap  .III.]  Ner  I  '0  US  Siroci:.  5  5 

Under  the  head  of  love  I  think  it  well  to  refer  iu 
another  class  of  cases,  which  probably  are  uncommon. 
I  have  seen  several  examples  in  which  young  men 
and  young  women  of  highly  sensitive,  and  sometimes 
of  strongly  religious  tendencies,  have,  like  some  of  the 
saints  of  old,  suppressed  their  passions  till  they  have 
seen  visions  appearing  to  them,  perhaps,  as  ghostly 
temptations  to  sin. 

FrigSit  aiicl  nervous  sliocU.— From  time  to 
time  a  good  many  diseases  of  the  nervous  system  have 
been  attributed  to  shock  or  fright,  but  just  as  at  the 
present  time  fewer  believe  in  fright  producing  chorea 
than  formerly,  so  I  believe  the  influence  of  fright,  in 
the  production  of  insanity,  is  looked  upon  as  less 
potent  than  it  was.  Yet  I  have  seen  several  cases  in 
which  there  could  be  no  doubt  that  fright  was  the  im- 
mediate cause  of  the  insanity.  Thus,  a  young  man 
returning  home  from  a  public-house  on  the  fifth  of 
November,  was  greatly  alarmed  by  a  practical  joke 
played  upon  him  by  some  of  his  companions,  who 
threw  squ.ibs  at  him  as  he  passed  along  a  dark  lane. 
On  the  morrow  he  was  found  in  his  bed  in  a  condition 
which  induced  his  brother  to  think  he  had  been 
drinking,  but  this  proved  to  be  an  attack  of  acute  de- 
mentia, from  which  he  suffered  for  some  months, 
but  ultimately  recovered,  v>'ith  absolute  oblivion  of 
the  period  which  had  intervened.  In  another  case,  a 
fire  in  the  house  set  up  an  attack  of  acute  mania, 
which  ended  fatally  within  a  week.  In  other  cases  I 
have  seen  less  sudden  shocks  act  as  disastrously.  I 
have  known  a  man  falsely  accused  of  theft,  and 
another  who  was  boycotted  by  his  fellows  without 
cause,  both  of  whom  for  some  weeks  led  a  life  of  great 
anxiety,  pass  into  conditions  of  insanity  of  longer  or 
shorter  duration.  I  could  give  many  other  examples 
in  which  frights,  such  as  those  occurring  from  acci- 
dents or  from  felonious  attacks,  have  been  follov/ed  by 


56         Lysax/tv  and  Allied  N'euroses,   [Chap.  hi. 

serious  mental  symptoms,  so  that  a  woman  assaulted 
with  a  criminal  intent  has  become  weak-minded,  and 
at  least  some  of  the  cases  of  post-connubial  insanity 
are  due  to  the  shock  of  marriage.  One  important 
point  to  be  remembered  is,  that  although  shock  or 
fright  may  occasionally  act  immediately  and  dii'ectl}^ 
yet  at  other  times  the  result  does  not  make  its  ap- 
pearance for  weeks  or  even  months  after  the  actual 
occurrence.  This  is  not  only  especially  true  in  the 
case  of  frights,  but  will  be  seen  constantly  to  occur 
with  the  more  ordinary  causes  of  insanity.  If  we 
trace  sufficiently  far  back,  a  single  exciting  cause  may 
seem  to  have  given  a  bend  or  inclination  in  the  whole 
nervous  life,  which  from  that  time  goes  on  to  degene- 
ration, and  not  to  evolution. 

Physical  causes :  Intemperance  in  drink. 
— Intemperance,  as  I  have  said  before,  is  a  Aery  mul- 
tiple agent  in  causing  insanity.  It  acts  upon  the  brain 
directly  as  a  poison  ;  it  acts  indirectly  upon  the  brain 
by  impairing  nutrition  and  interfering  with  the  depu- 
ration of  the  blood ;  it  acts  morally  by  lowering  the 
social  condition  of  the  majority  of  those  who  indulge 
to  excess,  and  indirectly  it  leads  to  injuries,  expo- 
sure to  cold,  and  similar  damaging  influences.  I 
shall  have  to  consider  insanity  as  specially  connected 
with  drink,  and  therefore  here  I  shall  but  briefly  give 
a  general  outline  of  its  action. 

Large  single  doses  of  stimulants  may  act  almost 
like  a  shock,  and  render  the  person  taking  them  power- 
less, or,  in  some  cases,  suddenly  maniacal ;  more  com- 
monly the  excess  in  drink  is  a  frequently-repeated 
act,  and  the  effects  are  the  result  of  the  constant  repe- 
tition, the  whole  nutrition  of  the  body  suffering.  It 
will  be  noted  that  in  these  cases  there  is  a  progres- 
sive loss  of  mental  power,  which  resembles,  in  many 
particulars,  the  progressive  loss  of  faculties  which  is 
seen  in  general  paralysis  of  the   insane,  the  higher 


Chap.  III.]  Intemperance.  57 

powers  of  self-control  being  earliest  lost,  the  moral 
sense  and  social  and  domestic  feelings  suffering  in 
turn,  till,  later  on,  memory  and  reasoning  power,  and 
finally  even  the  simpler  organic  nervous  actions,  are 
suspended. 

Intemperance  may  act  in  another  way.  Bouts  or 
recurrences  of  drinking  are  associated  with  repeated 
attacks  of  delirium  tremens,  these  attacks  shaking  the 
nervous  system  so  severely  that  in  the  end  it  totters 
and  falls,  I  have  seen  several  cases  belonging  to 
nervous  families  in  which  an  attack  of  delirium 
tremens  has  passed  directly  into  an  attack  of  acute 
mania,  persisting  for  weeks  after  the  alcoholic  poi- 
soning had  been  got  rid  of.  The  influence  of  drink  is 
greatly  increased  if  there  be  strong  inheritance,  so 
that  certain  persons,  who  might  have  become  insane 
from  some  other  cause,  become  insane  in  consequence 
of  drink,  as  it  were,  by  accident. 

Again,  the  effect  of  drink  in  producing  nervous 
disturbance  must  be  considered  in  connection  with  in- 
juries to  the  head.  I  have  known  several  cases  ad- 
mitted into  asylums  with  drink  given  as  the  cause  of 
insanity,  whereas  the  true  cause  was  injury  to  the 
head,  which  rendered  the  nervous  system  so  unstable 
that  a  slight  amount  of  drink  "flew  to  the  head,"  as 
the  friends  of  the  patient  graphically  expressed  it,  and 
seemed  to  stop  there,  for  the  balance  having  been  lost 
it  required  some  weeks  to  set  it  right. 

One  special  relationship  of  drink  to  nervous  disease 
is  the  direct  transmission  of  drinking  tendencies  from 
father  to  child.  I  have  known  a  drunken  father  be- 
get a  child  who  became  a  drunkard,  and  also  children 
who  have  been  idiotic  or  who  have  become  insane. 

Dipsomania  is  a  symptom  which  I  shall  discuss 
more  fully  later  on.  With  this  subject  of  intem- 
perance in  drink  I  must  insist  that  it  often  requires 
very   careful  discrimination  of  cases   to  be  perfectly 


58         Insanity  and  Allied  Neuroses.   [Chap.  hi. 

sure  tliat  drink  is  the  cause  of  the  insanity,  and 
not  one  of  the  earliest  symptoms.  For,  in  my  ex- 
perience, one  of  the  most  common  tendencies  of  early 
lunacy  is  to  seek  for  sleep,  relief  from  pain,  excite- 
ment, or  alleviation  of  trouble  in  drink.  In  such 
cases  the  nervous  disturbance  was  already  fairly 
started  before  the  drink  was  taken  to  excess ;  here, 
then,  drink  can  at  most  be  looked  upon  as  an  excit- 
ing, not  predisposing,  cause. 

Intemperance  in  other  forms  of  stimulation  or 
narcotism  must  be  noted.  Thus  morphia,  chloral 
hydrate,  sal -volatile,  or  tobacco,  may  act  almost 
exactly  in  the  same  way  as  stimulants.  Before, 
however,  leaving  this  subject,  I  would  say  that  if 
there  be  a  marked  increase  of  insanity  among  the 
educated  classes,  I  have  no  evidence  that  there  is  any 
direct  connection  between  the  increase  of  insanity  and 
any  increased  consumption  of  intoxicating  drinks. 
Amona:  the  lower  orders  it  has  been  shown  that  when 
wasfes  are  hio-h  and  work  abundant  sfreat  excesses  in 
drink  are  common,  and,  at  the  same  time,  insanity 
abounds  ;  but  that  with  strikes  and  depression  of  trade 
follow  teetotal  movements  and  decrease  of  admission 
to  asylums. 

Teetotalism  is  no  preventive  to  insanity,  for  we  are 
constantly  in  the  habit  now-a-days  of  seeing  patients 
who  have  been  teetotallers  for  years,  or  even  for  their 
whole  lives,  and  yet  have  not  staved  off  attacks  of  in- 
sanity. Among  total  abstainers  we  have,  of  course,  to 
recoo-nise  the  fact  that  a  certain  number  abstain  as  the 
earliest  symptom  of  their  insanity,  that  is,  of  their  per- 
version. They  are  suffering  from  mental  depression,  and 
feel  contrite  and  desirous  to  make  amends  for  the  past ; 
but,  as  the  Scotch  proverb  has  it,  "  when  the  devil  was 
ill,  the  devil  a  saint  would  be,"  so  the  drinker  has  be- 
come teetotal  as  a  symptom  of  his  melancholy;  and 
the  reaction  may  be  as  marked  as  the  original  fit  of 


Chap.  III.]  Sexual  Excess.  59 

abstinence,  the  unfortunate  drinker  again  returning 
with  fresh  vigour  to  his  cups,  when  the  wave  of 
depression  has  passed. 

In  some  cases,  after  the  depression  of  the  absti- 
nence an  ordinary  attack  of  insanity  may  follow,  or 
the  patient  may  become  changed  in  mental  character, 
and  remain  perverted  as  long  as  he  lives. 

Sexital  excess.  —  This  is  a  somewhat  delicate 
and  difficult  point  to  discuss,  not  from  any  feelings  of 
modesty  (for  to  the  physiologist  all  things  are  pure), 
but  because  the  practical  knowledge  of  the  physician 
is  limited  as  to  the  intimate  relationship  of  the  sexes, 
and  his  evidence  is  consequently  likely  to  be  im- 
perfect. It  is  quite  certain  that  the  modern  way  of 
associating  the  sexes  as  established  by  society  is  alto- 
gether unnatural  and  arbitrary.  The  sexual  instincts, 
which  were  originally  intended,  and  still  exist  in  the 
animals  most  nearly  allied  to  man,  purely  for  the  con- 
tinuation of  the  species,  have  been  in  the  human 
animal  cultivated  for  ages  as  a  special  source  of  plea- 
sure, out  of  relationship,  I  had  almost  said  in  direct 
opposition,  to  the  function  of  reproduction.  Sexual 
indulgence  is,  therefore,  gratified  under  every  kind  of 
stimulant,  and  without  any  definite  periods  of  rest. 
This  most  costly  of  functions  is  performed  in  the  most 
reckless  manner  by  immature  individuals,  v/ho  are 
wasting  not  only  their  physical  income  in  riotous 
living,  but  are  drawing  by  every  means  in  their  power 
upon  their  physical  capital.  Sexual  excess  is  a  purely 
relative  term.  What  would  be  excess  in  one  indi- 
vidual would  have  no  disastrous  effect  upon  another, 
and  it  will  be  ray  duty  to  point  out  what  I  consider  to 
be  the  symptoms  of  nervous  disorder  produced  di- 
rectly by  sexual  excess. 

In  some  cases  bursts  of  excess,  like  outbreaks  of 
drinking,  produce  sudden  disturbances,  and  I  have  seen 
several    cases    of   young    newly-married    people    who 


6o         Insanity  and  Allied  Neuroses.   [Ciiap.  in. 

were  rendered  emotional!)'  insane  in  consequence  of  a 
few  days'  sexual  orgie.  It  is  common  with  English 
authorities  to  look  to  sexual  excess  as  the  chief  cause 
of  general  paralysis  of  the  insane,  and  I  must  own 
that  I  have  noticed  that  the  wives  of  certain  general 
paralytics  are  representatives  of  what  I  may  call  the 
gross  animal  type  of  woman.  This,  however,  is  not 
evidence  that  they  or  their  husbands  have  indulged 
unduly  in  sexual  intercourse,  for  the  voluptuous  in 
appearance  are  not  always  the  amorous,  and  I  believe 
Ovid  would  have  associated  excess  rather  with  thin 
and  slender  women.  In  several  cases  I  have  received 
histories  of  epilepsy  occurring  for  the  first  time  about 
the  period  of  sexual  congress,  and  in  one  case  there 
seemed  to  be  distinct  relationship  established  between 
imperfect  sexual  congress  and  epilepsy,  followed  by 
insanity. 

Venereal  tlisease  (more  especially  syphilis). — 
Occasionally  young  patients  are  admitted  suffering  from 
considerable  mental  depression  with  general  hypochon- 
driacal symptoms,  associated  with  an  attack  of  gonor- 
rhoea. Such  patients  have  been  preparing  gradually 
an  attack  of  insanity,  which  has  been  simply  precipi- 
tated by  the  moral  and  physical  distress  induced  by 
the  gonorrhcea. 

The  many  ways  in  which  syphilis  acts  as  a  cause 
of  insanity  will  require  a  rather  lengthy  description,  and, 
like  many  of  the  preceding  causes  of  insanity,  may  have 
more  than  one  aspect  of  connection  with  unsoundness 
of  mind.  Many  insane  persons  contract  syphilis  after 
they  have  become  insane,  and  the  attack  of  insanity 
may  have  nothing  whatever  to  do  with  the  syphilitic 
disorder.  On  the  other  hand,  cases  are  seen  to  occur 
in  which  syphilis,  contracted  years  and  years  before, 
colours  the  hypochondriacal  melancholy,  and  gives  the 
malady  the  form  that,  by  some,  is  named  syphilo- 
phobia.     I  remember  some  years  ago  a  Persian  Avho 


Chap.  III.]  Syphilis.  6i 

was  in  Bethlem  suffering  from  a  form  of  simple  melan- 
cholia, which  for  weeks  seemed  to  be  without  any 
definite  delusion ;  the  patient  was  suffering  from 
simple  melancholy,  as  evidenced  by  his  whole  aspect, 
and  by  the  slowness  of  his  mental  action.  He  .said  he 
could  give  no  account  of  the  origin  of  his  misery ;  but 
after  careful  watching  it  was  noticed  that  he  Avas 
constantly  washing  his  underclothing,  and  on  one 
occasion  became  violent  because  another  patient  had 
taken  some  bread  which  he  had  touched.  It  soon  be- 
came evident  that  he  was  suffering  from  syphilophobia, 
and  feared  that  anything  which  touched  his  body 
might  convey  the  disease  to  others.  This  is  just 
another  example  of  the  roundabout  way  which  the 
insane  will  take  to  explain  the  misery  from  which 
they  suffer. 

Besides  the  mental  influence  of  an  attack  of 
syphilis,  we  may  have  patients  suffering  from  epilepsy 
produced  by  some  syphilitic  tumours  of  the  brain  or 
its  membranes,  and  the  insanity  may  be  in  every 
particular  like  that  occurring  with  ordinary  epilepsy. 
In  my  experience  it  is  more  common  to  get  progressive 
weak-mindedness  as  the  result  of  epileptic  fits  due  to 
syphilis  than  it  is  to  meet  with  attacks  of  mania 
directly  associated  with  the  fit.  Thus,  epilepsy  pro- 
duced by  syphilitic  tumours  within  the  skull  may 
tend  to  weak-mindedness,  and  allied  to  this  condition 
must  be  considered  some  cases  in  which  multiple 
syphilitic  tumours  have  affected  special  parts  of  the 
brain,  so  that  symptoms  which  were  indistinguishable 
from  those  of  general  paralysis  of  the  insane  have 
been  developed,  and  the  diagnosis  has  only  been 
cleared  up  at  the  j'^ost-mortem  examination.  Besides 
the  symptoms  associated  with  epilepsy,  we  may  have 
various  kinds  of  insanity,  such  as  mania,  melancholia, 
or  dementia,  connected  either  with  syphilitic  tumours 
in  the  skull,  or  with  syphilitic  disease  of  the  arteries. 


62         Insanity  and  Allied  Neuroses.   [Chap.  in. 

Cases  will  be  described  fully  in  which  various  per- 
versions of  intellect  have  been  directly  traceable  to 
coarse  syphilitic  lesions,  cases,  some  of  which,  at  least, 
have  been  cured  by  having  been  placed  under  proper 
treatment. 

Two  special  varieties  of  cases  are  noteworthy.  In 
the  first  of  these  there  has  been  some  severe  local 
disease  setting  up  sensory  perversion ;  thus,  a  patient 
with  double  optic  neuritis  due  to  syphilis  had  impaired 
vision,  and  as  a  result  became  suspicious  and  dan- 
gerous, thinking  people,  whom  he  saw  but  vaguely, 
were  going  to  injure  him  in  one  way  or  another.  In 
the  second,  tumours  of  the  brain  due  to  syphilis  may 
produce  epilepsy,  which  very  often  gives  rise  to 
some  symptoms  of  local  paralysis,  such  as  strabismus 
and  ptosis ;  such  symptoms,  by  the  way,  being  rare  in 
ordinary  cases  of  insanity  and  general  paralysis,  point 
often  directly  to  their  specific  origin.  In  some 
syphilitic  cases,  without  epilepsy,  the  mind  may  become 
deranged ;  in  these  we  are  obliged  to  suppose  that  the 
symptoms  are  due  to  syphilitic  arterial  change,  though 
I  must  say  at  present  I  have  no  pathological  grounds 
for  the  belief.  The  relationship  between  the  two 
maladies  is  this  :  a  man  having  had  syphilis,  followed 
by  constitutional  symptoms,  without  either  fits  or 
paralysis,  becomes  altered  in  character,  and  ultimately 
weak  in  mind.  The  only  explanation  is,  either  that 
the  disease  affects  the  general  nutrition,  or  so  injuri- 
ously affects  the  arteries  that  the  sujDply  of  nutrition 
is  limited.  This  possible  limitation  of  nutrition  leads 
us  to  consider  another  way  in  which  syphilis  may 
act. 

I  have  seen  several  patients,  who  have  been 
admitted  into  asylums,  suffering  from  insanity  with 
syphilis,  which  latter  has  been  persistently  and 
energetically  treated.  These  patients  were  extremely 
weak  and  cachectic,  but  whether  the  cachexia  was  due 


Chap.  III.]  Self-Abuse.  63 

to  syphilis  or  sypliili  :■  plus  treatment  I  cannot  say  ;  but 
in  any  case  I  believe  the  symptoms  were  more  due  to 
cachexia  than  to  syphilis  specifically. 

To  conclude,  syphilis  may  produce  moral-  perver- 
sion with  hypochondriacal  symptoms,  or  it  may  act 
directly  on  the  brain  by  means  of  tumour  or  impeded 
circulation ;  finally,  it  may  act  by  reducing  the  whole 
vitality  of  brain  and  body,  or  by  interfering  with 
recovery. 

§elf- abuse  fsexual). — This,  as  a  cause  of 
insanity,  is  certainly  fully  recognised  by  the  pro- 
fession and  the  world  at  large,  but  that  it  occurs  in 
both  sexes  is  not  so  fully  known.  In  handling  this 
subject  I  feel  more  than  ordinary  difficulty  in  ad- 
justing the  balance  without  u.ndue  inclination,  I 
have  already  said  that  youth  is  a  period  of  nervous 
instability,  and  that  it  is  a  period  when  smaller  shocks 
will  cause  an  upset,  or  derange  the  balance.  The 
whole  of  a  new  side  to  the  life  is  being  developed,  and 
the  hitherto  chiefly  egoistic  is  now  growing  out  of 
itself,  and  becoming  more  altruistic.  At  this  period 
of  instability,  excess  of  any  kind,  especially  excesses 
that  act,  not  only  on  the  body,  but  on  the  moral 
nature,  are  very  serious  in  their  consequences. 
Masturbation  is  probably,  in  a  large  proportion  of 
cases,  an  educated  vice.  It  is  taught  .  by  one  to 
another ;  but  I  liave  records  of  cases  both  of  boys  and 
girls  in  which  the  individuals  acknowledge  that  they 
developed  untaught  their  evil  habit,  and  they  have 
given  me  graphic  descriptions  of  the  way  in  which 
they  first  learnt  secretly  to  gratify  their  lusts. 
Masturbation  does  produce  a  certain  amount  of 
insanity ;  of  this  I  have  no  doubt  whatever  ;  but  it 
produces  insanity  chiefly,  if  not  solely,  in  those  who 
are  highly  nervous.  Such  patients  have  highly 
mobile  nervous  systems,  and  too  frequently  have 
precocity  both  in  mind  and  passion,  so  that  they  have 


64         Insanity  and  Allied  Neuroses.   [CLap.  in. 

been  forced  in  education,  and  at  the  same  time  have 
prematurely  developed  sexual  desires.  In  such  per- 
sons, masturbation  is  indulged  in  to  great  excess 
with  very  serious  results.  I  have  known  precocious 
sexual  development  associated  with  masturbation, 
which  was  began  without  teaching  before  the  indi- 
vidual was  five  years  of  age.  As  a  rule,  the  earlier 
the  masturbation  commences,  the  stronger  the  ner- 
vous inheritance,  and  the  greater  the  tendency  to 
insanity  as  a  result. 

Although  masturbation  is  a  frequent  cause  of 
insanity,  it  may  also  be  looked  upon  as  a  symptom. 
It  is  within  my  experience  that  many  patients  have 
behaved  with  perfect  self-control  till  becoming  insane, 
when  they  have  given  themselves  up  to  the  indul- 
gence of  this  vice,  so  tliat  it  is  not  safe  to  say  that 
a  person  suffering  from  insanity,  and  at  the  same 
time  indulging  in  masturbation,  has  produced  his 
insanity  by  this  vicious  and  destructive  habit.  Such 
cases  are  seen  among  young  women  and  boys,  who 
are  suffering  from  acute  mania.  They  are  seen  again 
among  general  paralytics  in  the  earlier  stage  of 
the  disease,  and  in  many  cases  of  puerperal  insanity, 
in  which  latter  cases  it  is  probably  connected  with 
local  irritation.  Masturbation,  as  a  symptom  of 
disease,  also  occurs  at  the  climacteric,  and  seems  to  be 
like  a  final  blaze  of  passion  before  its  complete  ex- 
tinction, or  at  least  its  altered  condition.  ,It  may 
again  occur  as  a  symptom  in  old  age.  I  have  even 
known  it  habitually  indulged  in  by  a  chronic  lunatic 
of  over  ninety  years  of  age.  Masturbation,  then,  may 
occur  as  a  cause  of  insanity  in  either  sex,  but  it  occurs 
still  more  frequently  as  a  symptom  of  mental  dis- 
order. 

Over-exertion. — In  considering  this  as  a  cause 
of  insanity,  I  follow  the  table  A,  although  I  have  but 
little    experience    of   simple    over-exertion  producing 


Chap,  iii.i  Sunstroke.  65 

insanity.  That  men  of  extreme  energy  and  un- 
bounded power  of  work  do  break  down  will  be  more 
fully  illustrated  under  the  head  of  general  paralysis. 
Such  men  seem  to  burn  the  candle  at  both  ends  ;  and 
as  an  example,  I  Avill  give  the  case  of  a  lawyer,  who, 
having  made  a  large  business,  married  a  young  wife 
who  was  fond  of  society,  and  who  induced  her 
husband  to  go  out  a  great  deal,  and  encouraged  him  in 
leading  an  active  political  and  parochial  life.  The 
work  of  this  many-sided  and  continuous  kind  ended 
in  premature  wear-out.  I  have  seen  a  few  cases  of 
young  athletes  who  have  become  insane,  but  I  have 
never  been  able  to  satisfy  myself  that  insanity  in  any 
way  depended  upon  the  exercise.  In  one  case  a 
famous  runner,  who  afterwards  became  a  clergyman, 
passed  through  stages  of  excitement  into  Aveak- 
mindedness,  and  as  intellect  disappeared  it  was 
noticeable  that  the  attitude  and  movements  of  the 
runner  persisted  even  longer  than  those  of  the 
clergyman.  In  one  other  case,  a  man  who  had  been 
in  the  habit  of  using  fifty-pound  dumb-bells  became 
insane;  but  I  should  hardly  like  to  say  that  the 
excessive  exertion  had  anything  to  do  with  it. 
Continuous  exertion,  however,  under  bad  hygienic 
surroundings,  is  a  cause  of  nervous  exhaustion,  and 
is  likely  enough  to  disturb  an  unstable  nervous 
system.  But  we  must  always  be  prepared  to  find 
that  the  over-exertion  taken  by  a  person  of  unsound 
mind  was  rather  the  result  of  his  insanity  than  a 
cause  of  it.  Many  patients,  in  the  earlier  period  of 
general  paralysis  of  the  insane,  will  walk  long- 
distances,  ftud  accomplish  what  appear  to  be  mar- 
vellous feats,  as  parts  of  the  disease ;  but  the  friends 
would  be  much  more  likely  to  attribute  the  symptoms  to 
the  exercise  rather  than  the  exercise  to  the  disease. 

Ss,iai§tr©Iie. — Although    sunstroke    produces    a 
certain  amount  of  insanity  yearly,  the  evidence  as  to 
F — 14 


66         Insanity  and  Allied  A^euroses.  [Chap  iii. 

its  causing  insanity,  in  England  at  all  events,  fre- 
quently is  small.  Just  as  during  the  summer  we 
expect  to  hear  of  rabies  and  hydrophobia,  so  with  a 
temperature  above  the  average  we  are  sure  to  hear 
of  sunstroke.  I  divide  the  cases  into  those  in  which 
the  sun  has  had,  first,  a  direct,  and  second,  an  indi- 
rect action  on  the  patient,  sunstroke  being  really  the 
cause  of  the  first  cases,  but  exhaustion  associated  with 
either  want  of  food  or  excess  of  stimulants,  together 
producing  the  disorder  in  the  latter.  Frequently 
cases  of  general  paralysis  are  supposed  to  have  been 
caused  by  sunstroke,  but  in  these  cases  the  fit  of 
unconsciousness  has  been  mistaken  for  sunstroke. 

Accident,  or  iiijtu^^  —  I  shall  consider  trau- 
matic insanity  more  in  detail  later  on,  but  here  I 
only  say  that  insanity  may  be  j^roduced  in  some  cases 
by  injuries  to  the  head.  Epilepsy,  undoubtedly,  with 
its  associated  mental  disorders,  may  be  produced  by 
head  injuries.  A  certain  number  of  cases  of  general 
paralysis  of  the  insane  have  also  been  traced  to  injuries 
of  one  part  or  another  of  the  nervous  system.  Thus, 
injuries  to  the  brain,  from  concussions  and  similar  inju- 
ries to  the  spinal  cord,  have,  in  my  experience,  given 
rise  to  the  disease.  As  already  noticed,  when  speaking 
of  the  effects  of  drink,  some  persons  who  have  been 
injured  in  the  head  are  more  unstable  nervously, 
and  are  more  liable  to  become  affected  by  other  ex- 
citing causes  of  insanity  than  they  were  before  the 
injury.  I  believe,  too,  that  injuries  to  the  brain  of  a 
parent  may  produce  nervous  instability  in  the  off- 
spring. That,  in  fact,  just  as  Brown  Sequard's  rab- 
bits exhibited  epilepsy  as  a  direct  inheritance  from 
parents  in  whom  epilepsy  had  been  produced  arti- 
ficially, so  human  beings  may  become  insane  as  a 
result  of  injury  to  the  heads  of  their  parents.  Injury 
to  the  head  may  act  indirectly  by  causing  some  bone 
depression   or  disease,  so  tl^at   inflammation   of  the^ 


Chap.  I  IT.]  Pregnancy.  67 

membranes  may  be  a  cause  of  the  disorder.  In  at 
least  one  case  I  have  seen  comparatively  slight  injury 
to  the  head  produce  insanity  in  a  lad,  who  was, 
however,  strongly  predisposed  to  insanity  by  direct 
inheritance. 

To  sum  up,  injury  may  produce  insanity, 
whether  it  affects  the  brain  or  spinal  cord.  It  may 
produce  symptoms  immediately  as  the  result  of  the 
injury,  or  the  symptoms  may  develop  secondarily  to 
some  altered  condition  of  nutrition.  It  is  a  ques- 
tion whether  effusions  of  blood  within  the  skull  may 
give  rise  to  nutritional  changes  at  the  cortex,  which 
may  end  in  insanity.  I  have  been  unable  to  decide 
from  any  cases  I  have  seen,  but  certainly  in  one  case 
of  general  paralj^sis,  where  early  and  severe  head 
injury  was  given  as  the  cause  of  the  disease,  there 
was  present  a  large  organised  membrane,  which  might 
have  had  its  origin  in  the  injury. 

Preg^nancy. — Under  this  cause  I  shall,  for  con- 
venience, put  together  pregnancy  and  all  the  condi- 
tions associated  with  parturition,  and  the  period 
succeeding. 

The  subject  of  puerperal  insanity  has,  from  time 
immemorial,  been  considered  as  a  special  one,  the 
only  speciality  really  being  causation.  In  puerperal 
insanity,  the  mental  disorder  has  nothing  special 
or  peculiar  about  it.  The  term  puerperal  "  mania," 
is  misleading,  for  we  may  have  mania,  melancholia, 
or  dementia,  directly  associated  with  pregnancy  and 
childbirth.  The  action  of  pregnancy  in  the  produc- 
tion of  nervous  disturbance  is  simple  and  straight- 
forward enough.  Just  as  at  puberty  there  is  a 
perversion  of  function  associated  with  the  early  de- 
velopment of  sexual  instinct,  so  with  the  perfection 
of  the  function  there  may  be  a  very  serious  alter- 
ation in  the  various  parts  of  the  body.  We  are  all 
sufficiently   used  to   the    cravings   of   the   hysterical 


6S         Insanity  and  Allied  Neuroses.  [Cbap.  in. 

girl  and  of  the  pregnant  woman,  and  though  I  would 
not  for  a  moment  consider  all  fanciful  desires  of  this 
nature  as  being  necessarily  associated  with  insanity, 
yet  I  am  sure  that  in  persons  of  nervous  stock 
the  tendency  to  peculiar  longings  is  more  marked 
than  in  those  of  greater  stability. 

Pregnancy  seems  to  cause  insanity  in  two  distinctly 
different  ways ;  or  perhaps  it  would  be  better  to  say 
that  at  two  distinct  periods  of  pregnancy  insanity  is 
likely  to  appear.  During  the  earlier  months,  at  the 
time  when  physical  disturbance  is  most  common,  and 
when  the  woman  is  suffering  from  sickness,  neuralgia, 
malaise,  and  restlessness  generally,  she  may  pass  into 
a  condition  of  insanity  which  may  disaj)pear  about 
the  end  of  the  fourth  month.  The  pregnancy  here  has 
acted  as  an  irritant,  if  I  may  so  say,  causing  irritation 
similar  in  many  respects  to  that  produced  by  ovarian 
tumours  or  uterine  affections,  first  inducing  ordinary 
bodily  symptoms,  and  later  developing  insanity  in 
persons  predisposed  to  it.  In  the  second  place,  we  find 
insanity  developing  during  the  later  months  of  preg- 
nancy ;  and  though  the  worry,  physical  and  mental, 
of  the  pregnant  condition,  has  been  the  chief  factor 
in  developing  the  disorder,  the  termination  of  the 
pregnancy  does  not  bring  mental  relief,  and  the 
patient  passes  from  a  state  of  insanity  of  pregnancy 
to  one  of  puerperal  mania.  In  most  cases  of  insanity 
connected  with  pregnancy,  or  the  puerperal  state, 
there  are  other  contributing  causes.  Inheritance 
plays  a  very  important  part,  and,  in  my  experience 
of  many  hundreds  of  cases,  I  should  say  that  inheri- 
tance is  the  chief  factor,  and  the  pregnant  condition  a 
secondary  one. 

Besides  the  physical  disturbance  produced  by 
pregnancy,  I  shall  have  to  consider  the  fact  that, 
under  certain  circumstances,  the  characters  of  the 
various  pregnancies  are  different,  Thus,  I  have  known 


Chap.  III.]  Pregnancy.  69 

insiiiiifcy  to  occur  only  Avith  male  pregnancies,  and 
I  believe  other  cases  liave  been  described  in  which 
they  have  taken  place  only  with  female  children. 
Pregnancy,  again,  is  likely  to  act  as  a  cause  of  in- 
sanity in  women  who  have  had  previous  attacks 
which  may  have  originated  from  other  causes ;  and 
what  is  most  common  in  my  experience  is,  for  a 
woman  who  has  had  several  attacks  of  puerperal 
insanity,  to  have  later  an  attack  of  insanity  with 
pregnancy,  the  nervous  system  becoming  more  and 
more  unstable,  and  a  very  slight  cause  disturb- 
ing the  balance.  Many  women  go  through  other 
causes  of  depression  without  suffering  nervously,  and 
yet  become  insane  with  each  pregnancy  or  each 
delivery. 

Insanity  may  follow  parturition,  there  having 
been  no  marked  insanity  before ;  it  may  be  an  exag- 
geration of  the  emotional  state  produced  by  the  pains 
of  labour.  Just  as  we  said  insanity  might  be  started 
by  a  fit  of  delirium  tremens,  so  an  attack  of  mania 
may  be  started  by  labour  pains.  Next,  ephemeral 
attacks  of  insanity,  may  follow  the  onset  of  milk, 
Alarming  symptoms,  such  as  fever,  high  j)ulse,  sleep- 
lessness, and  anxiety  may  occur  a  few  days  after 
delivery,  and  may  pass  off'  after  the  administration  of 
a  purge.  At  this  period  we  may  have  an  attack  of 
insanity  which  may  rapidly  pass  off  also,  and  in  my 
opinion  some  cases  of  infanticide  are  committed 
during  these  ephemeral  attacks  of  mania.  Puerperal 
convulsions  may  also  be  followed  by  insanity,  but  it 
is  not  specially  common  to  find  the  insanity  following 
any  unnatural  delivery.  A  certain  number  of  cases 
follow  delivery  under  chloroform,  and  we,  of  course, 
meet  with  cases  after  the  application  of  forceps ;  but 
by  far  the  larger  number  of  cases  that  have  fallen 
under  my  observation  have  succeeded  labours  which 
were  natural  in  every  particular. 


7©         Insanity  and  Allied  N'euroses.   [Chap.  iii. 

With  the  clanger  of  parturition  we  have  to  con- 
sider blood-poisoning.  I  have  seen  several  cases  of 
puerperal  insanity  in  which  ^;osi  mortein  there  were 
found  evidences  of  distinct  septic  poisoning,  but 
that  this  was  the  cause  of  the  insanity  I  am  not 
prepared  to  say.  It  is  a  generally  accepted  belief 
that  the  insanity  following  delivery  within  a  fort- 
night is  likely  to  assume  a  maniacal  form  ;  but  if 
the  insanity  come  on  at  a  later  period,  the  symptoms 
will  probably  be  melancholic.  At  almost  any  period 
after  delivery  symptoms  of  insanity  may  arise ;  and 
the  effect  of  lactation  is  difficult .  to  measure,  for 
though,  some  women  may  give  nourishment  to  their 
children  for  years  without  suffering,  others  will 
suffer  considerably  from  the  drain  of  a  few  weeks 
or  months.  It  is  thus  evident  that  persons  of  the 
nervous  type,  if  reduced  by  any  general  or  local 
cause,  are  likely  to  have  an  attack  of  insanity,  and 
in  such  cases  it  is  rare  to  find  one  cause  alone  pro- 
ducing the  effect.  A  woman  having  had  several 
children  in  rapid  succession,  and  having  suckled  the 
last  with  the  idea  that  by  doing  this  she  would 
avoid  the  risk  of  pregnancy,  discovers  that  she  is 
advanced  in  pregnancy  and  gives  up  suckling ; 
she  gets  through  her  confinement  fairly  well,  but 
again  suckles  her  child,  and  thus  reduces  herself  to 
a  very  weak  condition  of  physical  health.  She  be- 
comes sleepless  and  nervous,  fancying  that  she  is 
going  to  be  deserted,  or  that  something  is  going  to 
happen  to  her  children  and  herself,  and  finally  makes 
an  attempt  upon  her  own  life,  whereupon  she  is 
declared  to  be  insane,  and  is  placed  under  proper 
control.  The  weakness  produced  by  prolonged 
lactation  and  frequent  pregnancy  has  caused  the 
disorder. 

We  have  thus  seen  that  the  action  of  pregnancy, 
parturition,  and  lactation  may  be  simple  or  compound. 


Chap.  III.]  Uterine  Disorders.  7 1 

They  may  act  immediately,  or  the  result  may  be  post- 
poned for  some  time.  Several  of  the  more  common 
symptoms  of  the  insanity  of  this  period  are  gener- 
all}'-  placed  among  the  causes,  such  as  sleeplessness, 
jealousy,  dislike  of  husband,  or  family  jars. 

Uterine  £iaid  ovarian  disorders. —  I  fear 
that  in  asylums  comparatively  little  is  done  in  the 
way  of  careful  study  of  uterine  conditions.  For  my 
own  part,  I  have  been,  and  am  still,  afraid  that  by 
interfering  with  the  uterus  by  careful  and  repeated 
examination,  the  ideas  of  the  patient  would  be  con- 
centrated on  herself,  and  would  develop  hypochon- 
driasis, which  is  already  too  common.  Flexed  or 
misplaced  uteri,  with  simple  ulceration  of  the  os  or 
cervix,  may  produce  a  long  string  of  symptoms ;  but, 
on  the  other  hand,  the  concentration  of  thoughts  on 
the  reproductive  organs  is,  in  my  opinion,  fraught 
with  even  greater  danger.  I  have  seen  a  few  cases  in 
which  some  marked  mal-position  has  set  up  unmis- 
takable symptoms,  which  have  been  relieved  by  its 
removal.  In  one  case,  a  patient  suffering  from 
melancholia  recovered  on  the  replacement  of  a  pro- 
lapsed uterus ;  and  that  the  uterus  has  a  direct 
influence  upon  mental  action  may  be  seen  in  other 
ways.  I  have  seen  a  patient  suddenly  recover  after 
a  retro-uterine  hsematocele  had  developed ;  in  this 
case,  the  cure  rather  followed  the  physical  suffer- 
ing than  the  uterine  disease.  In  a  few  cases,  cancer 
of  the  uterus  has  been  at  least  associated  with 
insanity,  but  the  part  played  by  the  cancer  is  doubt- 
ful. It  may,  like  any  other  uterine  disease,  cause 
worry,  anxiety,  sleeplessness,  pain,  and  nervous 
exhaustion;  or  it  may  give  colour  to  the  insanity 
itself,  so  that  the  patient  with  cancer  of  the  uterus 
may  declare  that  she  has  a  menagerie  in  her  inside. 
In  one  recent  case,  cancer  developed  itself  both  in  the 
uterus  and  breast,  the  association  being  interesting  as 


72         Insaaity  and  Allied  Necroses.   [Chap.  iii. 

occurriijg  in  the  two  distinct  parts  of  tlie  repro- 
ductive system. 

Next  as  to  the  effect  of  ovarian  disease  on  insanity. 
There  is  a  class  of  hysterical  patients  whose  symptoms 
become  sufficiently  grave  to  require  their  removal  to 
an  asylum,  in  whom  one  meets  with  ovarian  tenderness, 
swelling,  and  irregularity  of  menstruation,  sometimes 
with  menorrliagia.  And  although  the  insane  symp- 
toms do  not  dejDend  on  ovaritis,  the  whole  group 
of  symptoms  is  intimately  connected.  I  have  found 
ovarian  enlargement  and  tenderness  associated  with 
melancholia  with  stupor,  and  a  profuse  flow  of  saliva. 
In  some  of  the  cases,  treatment  directed  to  the 
ovaries  produced  beneficial  results,  I  have  seen 
about  six  cases  of  ovarian  dropsy  associated  with 
insanity,  and  I  shall  later  give  particulars  of  the 
symptoms  seen  with  the  association  of  these  two 
diseases.  They  seemed  to  be  of  two  descriptions ; 
with  the  one  were  associated  the  earlier  symptoms 
of  the  ovarian  disease,  i.e.  irritability  passing  into 
mania ;  with  the  others  were  associated  hypochon- 
driasis and  melancholia.  Unfortunately  none  of  the 
cases  were  in  such  a  condition  as  to  justify  surgical 
interference  :  the  only  one  which,  having  improved 
considerably  in  general  health,  Avas  temporarily  trans- 
ferred to  general  hospital  for  operation,  died  suddenly 
from  rupture  of  the  cj^st. 

To  sum  up,  insanity  may  be  started  either  by 
serious  uterine  or  ovarian  disease,  and  the  symptoms 
may  have  some  direct  relationship  to  the  seat  of  the 
disorder. 

Paitoerty. — We  have  I'eferred  to  this  in  connec- 
tion with  the  causation  of  insanity  among  the  predis- 
posing causes.  We  also  referred  to  it  when  con- 
sidering sexual  causes  and  self-abuse.  The  period  of 
puberty  is  one  of  special  danger  in  families  with 
the  neurotic  taint.      At  this  period,  too,  phthisis  and 


Chap.  III.]        TuiL  Climacteric  Period.  73 

allied  disorders  are  most  common,  and  tlie  body, 
being  hardly  as  yet  firmly  set,  cannot  withstand  any 
extra  shock.  The  forms  of  insanity  occurring  at  this 
period  are  chiefly  characterised  by  their  tendency 
eith(T  to  get  well  rapidly  or  else  to  pass  directly  into 
a  condition  of  weak-mindedness.  As  we  saw  that  in 
childhood  the  necessary  result  of  nervous  disease  was 
idiocy  or  imbecility,  so  now"  we  see  that  a  common 
end  of  acute  insanity  at  or  about  the  period  of 
puberty  is  dementia  or  chronic  weak-mindedness, 

Climactei'iCo — At  the  other  end  of  life,  answer- 
ing in  many  respects  to  the  period  of  puberty,  we 
meet  with  a  time  in  which  the  whole  system  is 
unstable  and  ready  to  develop  unhealthy  tendencies. 
At  this  period,  the  reproductive  organs_,  specially  in 
w^omen,  may  develop  morbid  growths,  so  that  cancer  of 
the  breast  or  uterus  is  most  commonly  first  met  with 
about  this  time  of  life.  Elsewhere  I  have  said  that  a 
climacteric  period  occurs  in  men  as  well,  though  not 
so  well  marked  as  among  women.  At  the  climacteric 
there  is  a  well-recognised  intellectual  change  common 
among  women,  so  that  they  may  become  more  fully 
intellectually  developed  than  at  any  earlier  period  : 
they  pass  into  a  state  of  mind  and  body  which  is  best 
described  as  one  of  greater  freedom.  Many  great 
writers  among  women  have  done  their  best  work 
after  the  menojDause  :  but  this  increased  activity  is 
evidence  of  considerable  change  in  the  nervous  and 
bodily  relations,  and  it  is  not  surprising  that,  in  some 
cases,  instead  of  intellectual  development  there 
should  be  signs  of  intellectual  decay.  The  chief 
characteristic  of  insanity  at  this  period  is  a  hypo- 
chondriacal habit  of  mind,  so  that  patients  of  one 
group  consider  that  they  have  mis-spent  their  lives, 
and  that  they  are  morally  ruined  ;  while  those  of 
the  other  group,  developing  the  same  sort  of  ideas, 
consider   they  have    either    injured    their    bodies,   or 


74         Insanitv  AXD  Allied  Neuroses.    [Chap.  hi. 

have  in  some  way  become  changed  or  unnatural. 
Other  symptoms  exhibiting  sense  perversion  are  not 
uncommon,  and  may  possibly  be  ex^Dlained  upon  the 
theory  that  they  are  the  ordinary  symptoms  of  the 
climacteric  insanely  interpreted.  Thus,  it  is  common 
for  women t of  about  forty-five  years  of  age  to  com- 
plain of  feelings  of  heat  and  oppression  on  the  crown 
of  the  head,  and  of  feelings  of  heat  and  cold  all 
over  the  body.  It,  however,  requires  the  insane 
person  to  explain  these  feelings  by  saying  she  has 
something  hot  and  alive  in  her  head,  or  that  chloro- 
form, chloride  of  lime,  or  ammonia  are  thrown  over 
her.  The  climacteric  is  associated  with  changes  in 
the  reproductive  functions,  and,  as  a  consequence, 
there  are  frequently  hallucinations  of  smell.  I  am 
impressed  with  the  fact,  that  where  we  have  ovarian 
troubles  we  may  expect  to  find  hallucinations  of 
smell  and  touch. 

Fevers. — It  is  comparatively  rare  to  receive 
patients  into  Bethlem  whose  insanity  depends  di- 
rectly upon  fever,  but  there  are  two  distinct  con- 
ditions under  which  mental  disturbance  is  developed 
from  febrile  diseases. 

In  the  first  the  initial  delirium  of  a  fever,  such  as 
scarlet  fever,  may  start  the  morbid  process,  and  the 
patient  pass  from  delirium  into  mania.  During  the 
past  eleven  years  there  have  been  admitted  some  half- 
a-dozen  cases  of  fever,  mistaken  for  acute  mania.  I 
have  thus  had  cases  of  small-pox  and  scarlet  fever ; 
and  although  I  should  have  been  prepared  to  find  that 
typhoid  fever  might  also  have  given  rise  to  the  same 
kind  of  error,  yet  so  far  I  have  not  met  with  it. 

Next,  after  fevers,  patients  may  pass  into  various 
states  of  mental  unsoundness.  This,  however,  does 
not  depend  upon  any  special  hyper-pyrexia,  nor,  as 
far  as  I  know,  on  any  special  complication  in  the  fever 
itself.     It  is  due  more  to  the  predisposition  to  nervous 


Chap.  III.]  Fevers.  75 

diseases  generally,  and  to  some  accidental  predisposi- 
tion that  may  have  been  acquired  or  inherited  which 
conduced  to  the  fever.  Sir  William  Jenner,  years 
ago,  at  the  Clinical  Society,  pointed  out  the  existence 
of  special  family  inheritance  of  predisposition  to  acute 
febrile  diseases  ;  and  any  one  who  has  had  experience 
of  ordinary  general  practice,  well  knows  how  certain 
families  are  attacked  in  all  epidemics  which  visit  the 
districts  in  which  they  reside,  while  others  are  free. 

One  other  important  consideration  is,  whether 
such  persons  belong  to  what  may  fairly  be  called  a 
nervous  stock.  For  although  I  have  but  limited  ex- 
perience of  such  families,  many  of  those  who  have 
come  under  my  notice  have  had  insane  and  otherwise 
neurotic  relatives.  Observations  have  been  made  at 
the  Fever  Hospital  in  reference  to  two  important 
questions  j  first,  whether  patients  suffering  from 
fevers,  who  have  mis-shapen  heads,  are  more  subject 
to  delirium  than  others ;  and  again,  whether  patients 
with  nervous  histories  are  more  liable  to  delirious  ex- 
citement. But  I  believe  that  as  yet  no  decision  has 
been  arrived  at  on  these  points.  It  is  generally  ad- 
mitted now  that  in  fevers  there  must  necessarily  be 
some  primary  or  secondary  nervous  disturbance. 

In  some  cases,  as  a  result  of  fever  there  is  tem- 
porary or  permanent  weak-mindedness,  chiefly  evi- 
denced by  irritability  and  selfishness.  This  may  pass 
into  a  condition  of  dementia  which  may  be  but  slowly 
recovered  from.  We  meet  with  such  mental  perver- 
sions following  the  continued  fevers,  also  with  small- 
pox, scarlet  fever,  cholera,  and  rheumatic  fever.  I 
have  seen  various  forms  of  mental  weakness  suc- 
ceeding rheumatic  fever,  both  with  and  without  hyjDer- 
pyrexia.  Having  no  personal  experience  of  tropical 
fevers,  malarial  or  other,  I  think  it  best  to  leave  on 
one  side  the  consideration  of  reported  cases  of  nervous 
disturbance  following  them. 


76         Insanity  AND  Allied  Neuroses.    [Chap.  hi. 

To  conclude  this  part  of  causation,  I  would  say 
that  insanity  may  be  started  by  the  initial  processes 
of  the  fever,  or  may  be  sequelae  of  the  febrile  process. 
These  conditions  may  affect  those  predisposed  by 
inheritance,  or  others. 

Fffivatioii  and  starvation.— Privation,  as  a 
cause  of  general  debility,  may  predispose  to  insanity, 
and  react  very  sei'iously  on  those  who  are  beginning 
to  show  signs  of  mental  disorder.  Starvation  is  more 
commonly  a  symptom  than  a  cause,  and  I  shall  have 
to  point  out  the  various  reasons  which  may  induce 
patients  to  refuse  their  food.  The  discussion  of  this 
subject  will  be  found  under  Melancholia. 

Old  age. — This  acts  in  several  ways,  and  as  a 
patient  recently  said  to  me,  he  felt  that,  like  Swift, 
he  was  "dying  from  the  top."  Many  cases  do  die  by 
their  nervous  systems  degenerating  along  the  line  of 
highest  development;  and  as  a  seed  contains  poten- 
tially a  tree,  so  a  man  may  be  born  with  tlie  tendency 
to  break  down  at  a  certain  period  in  a  definite  way.  I 
have  seen  such  cases  of  families  in  which  there  ap- 
peared to  be  a  dangerous  and  almost  fatal  period  of  life. 
I  have  seen  patients  suffering  from  emaciation  and 
active  melancholia  at  sixty-five  years  old,  and,  on 
inquiring,  I  have  heard  that  a  parent  and  a  grandparent 
had  broken  down  in  a  similar  way  at  a  like  age.  I 
have  seen  a  man  attacked  with  dementia  at  between 
sixty  and  seventy  years  of  age,  his  mother  having 
suffered  similarly.  There  is  nothmg  very  suriDrising 
in  this.  One  sees  cases  in  which  apoplexy,  kidney 
disease,  heart  disease,  lung  disease,  or  gouty  troubles 
develop  in  members  of  the  same  family  and  at  about 
the  same  period.  Later  I  shall  refer  to  the  connection 
between  the  diseases  of  age  and  insanity. 

Naturally  man  passes  from  middle  and  mature 
life  slowly  into  "the  lean  and  slippered  pantaloon." 
He    should,    according  to  the   dramatist,    pass    from 


Chap.  III.]  Old  Age.  77 

sanity  into  a  condition  of  folly,  but  fortunately  only 
a  small  proportion  follow  this  precept  to  tlie  letter. 
Age,  with  accompanying  brain -wasting,  may  be 
chiefly  marked  by  loss  of  self-control,  as  evidenced 
by  loquacity  or  irritability ;  or  by  change  of  habits, 
by  niggardliness  with  dread  of  ruin  ;  or  there  may 
be  outbursts  of  passion  and  lust.  It  does  not, 
however,  follow  that  wasting  of  brain  should  be 
directly  and  immediately  associated  with  wasting  of 
all  intellectual  capacity  ;  for  we  meet  many  an  old 
man  whose  memories  of  the  past  are  rich  and  varied, 
who  may  yet  be  the  subject  of  progressive  senile 
weak-mindedness,  as  shown  by  some  of  the  symptoms 
above  mentioned.  In  age,  the  check,  self-control,  is 
removed  in  one  man,  and  the  result  may  be  maniacal 
excitement  of  a  peculiar  kind,  rapidly  tending  to 
exhaustion  of  body  and  destruction  of  mind.  In 
others  the  brain-changes  are  followed  by  melancholia, 
and  the  man's  mind,  like  his  body,  seems  to  go  on 
crutches.  He  thinks  and  moves  painfully,  the  result 
of  the  bad  nutrition  of  his  brain  being,  that  he 
feels  the  very  working  of  his  mind  just  as  he  feels 
the  digestion  of  his  food.  The  perception  of  these 
unusual  sensations  gives  him  pain  and  causes  concen- 
tration of  his  ideas  upon  himself,  this  being  the 
chief  factor  of  the  development  of  melancholy. 

A  third  condition  is  that  of  simple  childishness,  in 
which  some  peculiarity  or  habit  of  the  man's  life 
becomes  more  accentuated,  so  that  the  antiquarian 
and  collector  becomes  a  very  magpie  in  collecting, 
or  the  domestic  man  becomes  uxorious,  only  happy 
when  surrounded  and  attended  to  by  all  his  suffering 
family. 

Age,  then,  in  some  families  shows  itself  in  brain- 
weakening  in  parent  and  child  in  direct  line,  or  it 
may,  by  simple  degeneration,  produce  various  forms 
of  mental  weakness  due  to  brain-ageing. 


78         Insanity  and  Allied  Neuroses.   [Chap.  ni. 

Other  bodily  diseases  and  disorders  of  function 
will  be  considered  later  in  their  relationships  to 
mental  symptoms.  I  have  repeatedly  expressed  my 
belief  in  the  fact  that  every  disease  has  a  nervous  or 
mental  aspect^  and  that  it  is  but  a  question  of  degree 
whether  a  person  is  insane  or  not,  whether,  in  fact, 
the  disturbance  of  the  nervous  system  by  bodily  dis- 
ease is  so  slight  as  to  be  merely  represented  by  pain, 
irritability,  or  general  malaise,  or  whether  it  is  more 
pronounced,  assuming  some  form  of  recognised  in- 
sanity. 

Heredity. — In  order  to  complete  the  table  of 
physical  causes  of  insanity,  I  must  again  call  at- 
tention to  hereditary  infiuence,  direct  and  indi- 
rect, as  causes  of  insanity ;  the  only  point  to  be 
added  being  that  inheritance  acts  from  a  mental  as 
well  as  from  a  physical  side.  The  fact  that  a  father 
or  mother  has  died  of  insanity  is,  in  many  cases,  a 
perpetual  worry,  which  is  in  itself  a  cause  predisposing 
to  the  disease. 

Cong-enital  defects  of  all  kinds,  but  chiefly 
those  of  the  senses,  have  a  very  distinct  influence  on 
the  mental  life  of  the  individual.  A  person  blind, 
deaf,  and  dumb  is  almost  necessarily  an  idiot,  though 
it  is  possible  that  with  an  enormous  amount  of 
trouble  and  special  training,  such  an  individual  can  be 
taught  a  considerable  number  of  things  through  the 
common  sensibility  of  the  skin  ;  but,  as  a  rule,  a  being 
whose  intelligence  is  starved  by  the  obliteration  or 
want  of  development  of  the  senses  will  be  but  feeble- 
minded. Tlie  superintendents  of  deaf  and  dumb 
asylums  confirm  one's  impression,  that  children  who 
for  years  had  been  shut  out  to  a  very  great  extent 
from  communion  with  the  outer  world  are  much  below 
the  average  in  intellect ;  and  in  fact  I  know  that  one  of 
the  greatest  of  difficulties  which  these  superintendents 
have  to  contend  against  is  that  a-  large  number  who 


Chap,  mo  Bodily  Deformities.  79 

are  sent  to  theui  are  practically  without  any  real  edu- 
cation. Tliey  are  perhaps  eleven  or  twelve  years  of 
age,  and  have  for  that  period  been  neglected,  so  that 
the  animal  side  of  their  nature  has  developed  without 
any  controlling  influence  in  proportion.  I  have  had  in 
Bethlem  cases  of  insanity  in  the  deaf  and  dumb,  and 
have  found  such  cases  extremely  difficult  to  influence. 
I  would  say  that  congenital  sense  defects  tend  to  in- 
sanity and  weak-mindedness,  directly  through  a  loss  of 
knowledge,  and  indirectly  as  making  a  patient  more 
keenly  sensitive  in  other  particulars. 

This  leads  me  to  note,  in  passing,  the  influence 
of  bodily  deformities  in  the  production  of  insanity. 
Anything  which  causes  the  thoughts  and  feelings 
of  a  patient  to  be  concentrated  upon  himself  is  un- 
healthy, and  any  deformity  has  such  a  tendency.  I 
can  readily  recall  several  such  cases  from  among 
patients  in  Bethlem.  One  woman,  who  for  years  had 
been  called  the  pig-faced  woman,  and  who  wore  very 
thick  veils  to  hide  her  facial  peculiarities,  at  last  be- 
came violent,  and  attacked  people  without  reason. 
Another  patient  with  peculiar  formation  of  face  (who 
by  the  way  attributes  her  peculiarity  to  a  fright  her 
mother  received  from  a  bull),  fancied  people  were 
shunning  her ;  and  it  is  comparatively  common  to 
meet  with  cases  of  sensitive  young  men  who,  because 
they  have,  or  think  they  have,  some  facial  peculiarity, 
withdraw  themselves  from  the  society  of  their  fellows 
and  endeavour  to  make  up  for  the  social  life  by  a 
studious  subjective  one.  Such  cases  not  unfrequently 
develop  some  form  of  insanity  with  ideas  of  persecu- 
tion or  annoyance,  and  the  patients  so  suffering  fancy 
they  are  specially  selected  by  society  as  butts. 

No  table  would  be  complete  without  a  provision 
for  unknown  and  unascertained  causes ;  for  the 
outer  world  not  being  very  critical  as  to  symptoms, 
often  mistakes  the  symptoms  for  the  cause,  so  that 


8o    ,    Insanity  and  Allied  Neuroses.    [Chap.  iv. 

we  must  be  prepared  for  fresh  exciting  causes  of  in- 
sanity with  every  fresh  scientific  improvement,  social 
disturbance,  or  political  excitement.  The  telephone, 
the  Salvation  Army,  or  a  change  of  government, 
may  each  act  as  the  last  grain  of  sand  which  turns 
the  balance,  and  the  only  moral  I  would  draw  from 
this  is,  that  we  must  avoid  being  ourselves,  like  the 
lunatiC;  too  ready  to  explain. 


CHAPTER    lY. 

HYSTEEIA   AND    ITS    RELATIONSHIPS. 

Hysteria  in  insane  families — Hysteria  as  an  early  symptom  of 
insanity  —  Hysteria  alternating  with  insanity  —  Grave 
hysteria  seen  in  asylums — Hystero- epilepsy — Neurastlienia. — 
Massage — Hysterical  mania — Aciite  delirious  mania — Typho- 
mania. 

As  a  branch  of  the  nervous  tree,  hysteria  must  be 
here  considered  in  some  of  its  various  relationships 
with  other  neuroses,  but  space  will  fail  me  to  fully 
describe  hysteria  as  it  occurs  ordinarily  and  in  its 
simplest  form.  T  shall,  in  considering  this  subject, 
refer  to  the  graver  forms  of  hysteria,  to  those  forms 
which  are  to  be  seen  in  general  hospitals  or  in 
asylums ;  cases  which  have,  from  some  cause  or 
another,  been  found  to  be  intractable  at  home.  The 
common  feeling  is  one  of  regret  that  such  cases  are 
sent  to  asylums  at  all,  and  friends  think  that  it  is  a 
mistake  for  such  simple  cases  of  nervous  disorder  to  be 
sent  to  associate  with  the  insane.  Yet,  as  I  shall 
point  out,  some  such  cases  will  die  unless  sent  away 
from  their  old  surroundings,  and  in  my  experience 
asylum  treatment  has  often  cured  when  hospitals  have 
failed.     Every  shade   of   nervous  disorder^  from  the 


Chap.  IV.]  Hysteria  as  a  Symptom  of  Insanity.   8i 

simplest  emotional  storm  of  laugliter  witli  tears,  up  to 
violent  mania,  may  occur  with  what  may  be  properly 
called  hysteria.  I  find  it  difficult  to  draw  any  line 
between  cases  of  simj^le  mania,  with  mischievous  ten- 
dencies occurring  in  young  nervous  women,  and  cases 
which  are  classed  as  hysterical  mania.  There  are 
many  gradations  between  the  simple  and  severe  nerve- 
storms. 

Simple  hysteria  is  comparatively  rare  among  the 
inmates  of  an  asylum.  It  may  seem  somewhat  para- 
doxical to  say  that  hysteria  is  a  branch  of  the  nervous 
tree,  and  yet  that  in  an  asylum  one  rarely  meets  with 
hysterical  fits ;  but  frequently  months  pass  over 
without  a  single  case  of  hysterical  fits  occurring 
among  the  one  hundred  and  fifty  to  two  hundred 
female  patients  in  Bethlem. 

The  relationsliip  of  hysteria  to  insanity  is  manifold. 
In  the  first  place  hy  origin.  The  same  parentage 
will  produce  insanity  in  one  member  of  a  family  and 
hysteria  in  another,  the  hysterical  person  perhaps 
spending  a  long  life  without  ever  having  more  than 
severe  attacks  of  hysteria,  although  exposed  as  nearly 
as  possible  to  the  same  surroundings  and  influences  as 
those  which  have  produced  insanity  in  a  sister. 

In  the  second  place,  hysteria  may  he  the  earlier 
symptom  of  nervous  disorder  which  leads  on  to  in- 
sanity, and  I  shall  have  to  refer  to  cases  in  Bethlem 
who  have  suffered  in  various  ways  with  hysteria,  which 
has  later  developed  into  insanity. 

In  the  third  place,  we  may  have  ordinary  cases 
of  hysteria  becoming  exceptionally  troublesome,  and 
although  these  are  still  looked  upon  as  cases  of  hysteria, 
yet  they  may  require  to  be  secluded. 

With  this  introduction,  I  pass  to  the  consideration 
of  hysteria  as  it  presents  itself  to  those  connected 
with  asylums. 

I  think  it  unnecessary  to  give  a  definition  of  what 
G— 14 


82        Insanity  and  Allied  Neuroses.    [Chap,  iv. 

I  mean  by  hysteria,  as  the  examples  given  will  serve 
best  to  pour  tray  the  disorder,  and  I  shall  feel  less 
hampered  by  having  no  definition  to  confine  me. 

Alternation   of  hysteria    and   insanity. — 

One  woman  admitted  twice  into  Bethlem,  on  each 
occasion  suffering  from  the  most  violent  acute  mania, 
had  a  history  of  hysterical  paraplegia,  which  had 
lasted  for  a  considerable  time  before  admission ; 
the  para^Dlegia  passed  off,  to  be  succeeded  by  the 
acute  mania.  In  another  case  there  was  an  alterna- 
tion in  the  symptoms,  so  that  the  girl, .  when  maniacal, 
was  able  to  do  mischief,  but  when  she  became  quiet, 
hysterical  paraplegia  rendered  her  passive.  Such 
cases  as  these  are  not  very  uncommon,  and  the  history 
of  their  coming  into  an  asylum  is,  that  to  the  physical 
weakness  which  sent  them  to  the  hospital,  some 
moral  perversions  are  added.  Thus,  a  young  married 
woman,  a  patient  in  a  general  hospital,  was  treated 
for  some  vague  and  ill-defined  form  of  paraplegia.  It 
was  supposed  to  be  hysterical  by  the  physician  under 
whose  care  she  was  placed.  After  a  few  weeks'  resi- 
dence she  became  discontented  and  troublesome, 
utterly  regardless  of  truth,  and  with  a  loss  of  sense  of 
what  was  right  in  other  particulars  ;  so  that  what  with 
disturbing  patients  at  night  by  her  screaming,  and 
stealing  small  articles,  and  causing  additional  confu- 
sion by  her  untruthfulness,  she  was  considered  unfit 
for  the  hospital,  and  was  transferred  to  the  asylum, 
where,  after  months  of  treatment,  by  means  of  gal- 
vanism and  other  stimulants,  she  was  discharged  re- 
covered. 

Other  cases,  in  which  hysteria  is  well  marked, 
lose  self-control  and  give  vent  to  passion,  or  become 
mischievous  and  mendacious  ;  and  with  a  still  further 
development  of  nervous  weakness  and  instability, 
begin  to  imagine  that  people  are  bent  upon  in- 
juring their  character  and  reputation ;  or  they  may 


Chap.  IV.]  Loss    OF   SENSIBILITY.  83 

develop  emotionally  religious  ideas,  and  get  delu- 
sions as  to  the  intentions  of  the  curate  or  some 
member  of  their  church.  Such  morbid  develop- 
ments are  common  enough,  and  show  that  in  these,  as 
in  most  other  cases  of  mental  disorders,  insanity  is  a 
consistent  growth.  The  symptoms  develop  them- 
selves out  of  an  unrestrained  or  ill-regulated  sexual 
passion^  which  disturbs  first  the  emotional  side  of 
the  character,  and  affects  later  the  associated  social 
relations,  thereby  destroying  first  the  ideas  of  pro- 
priety as  regards  the  sexes,  and  next  the  require- 
ments of  organised  society  regarding  truth  and  honesty. 
Memory,  sense-perception,  and  intellect  may  persist 
normally,  though  the  patient  rarely   admits  she  has 

had  knowledo-e  of  what  she  has  said  or  done  during 

.  ...  ^ 

the  period  of  excitement ;  and  in  this  I  think  may  be 

found  a  useful  means  of  distinguishing  these    cases 

from  ordinary  cases  of  mania,  for  the  maniacal  patient 

ordinarily  has  a  memory  of  what  has  gone  on  around 

him,   and    on  recovery  is   willing,   even  anxious,  to 

recall  or  refer  to  what  has    taken  place,  while  the 

hysterical  woman  will  deny  having  any  recollection  of 

the  past. 

The  senses  may  be  perverted,  and  if  they  are,  it  is 

generally  in  the  way  that  is   noteworthy  among  the 

ordinarily   hysterical.       Patients    may    have    loss    of 

common  sensibility,  and  in  this  case  the  one  half  of 

the  body  may  become  anaesthetic,  and  I  have  known 

girls  burn  themselves  unconsciously  when  in  such  a 

condition.      In  the  case  of  one  girl  in  Bethlem,  who 

might  be  fairly  placed  in    this  group,  a  finger  was 

eaten  by  the  rats  without  her  withdrawing  it  from  the 

hole  in  which   she    had    placed  it,    and  at   the  time 

she  told  me  that  she  held  it  there  for  a  man  to  kiss, 

and  that  she  was  not  going  to  withdraw  it  while  he 

was   kissing  it.     In   another  case    a   girl  introduced 

broken  pieces  of  needles  and  pins  between  her  eyelids, 


84         Insanity  and  Allied  Neuroses.    [Chap.  iv. 

and  when  I  was  called  to  see  her  she  at  once  accused 
me  of  having  done  it  myself.  There  is,  more  rarely, 
loss  of  colour-sense,  and  in  some  cases  there  is  altera- 
tion in  the  auditory  sense  ;  and  from  the  filthy  habits, 
such  as  the  eating  of  faeces,  developed  by  some  cases,  1 
believe  the  sense  of  taste  and  smell  must  be  impaired. 
In  one  young  girl,  who  had  several  attacks  of  insanity, 
associated  with  precocious  sexual  development,  a  habit 
of  reading  everything  upside  down  was  developed,  and 
if  a  book  Avere  placed  in  the  ordinary  position  she 
would  pass  into  a  convulsive  state,  which  she  said  she 
could  not  help,  but  that  the  fit  depended  upon  the 
book  being  placed,  as  she  said,  wrong.  This  patient 
was,  however,  convinced  of  her  delusion,  if  I  may  use 
the  term,  by  the  stratagem  of  asking  her  to  write  her 
naine  in  a  birthday-book,  which  she  did  correctly,  and 
not  inverted.  All  the  manifold  tales  one  hears  of  mi- 
racles, all  the  tales  of  ghosts,  many  of  the  instances  of 
the  thought-reader  and  spiritualist,  are,  in  my  opinion, 
the  result  of  cases  of  hysterical  insanity.  The  old  idea 
that  wherever  any  trouble  was  present  there  was  sure 
to  be  a  woman,  is  confirmed,  in  my  opinion,  by  the 
fact  that  whenever  strange  manifestations  take  place 
which  are  beyond  the  sphere  of  observation  by  our 
senses,  there  will  be  found  a  girl  with  hysterical  his- 
tory, or  otherwise  distinctly  neurotic.  But  to  continue, 
besides  the  comparatively  harmless  disturbances  which 
may  be  produced  in  a  family  by  the  presence  of  an  hys- 
terical member,  the  patient  may  develop,  either  from 
religious  motives  or  from  some  feeling  of  gastric 
uneasiness,  ideas  that  it  is  wrong  to  take  food.  One 
girl  will  think  she  is  commanded  to  take  only  bread 
and  water ;  or  another  that  bread  is  not  intended,  only 
water  ;  another  will  think  she  is  only  to  take  food 
under  very  special  conditions,  so,  unless  she  has  done 
a  certain  act  or  has  exercised  a  certain  self-restraint, 
she    is   not    entitled  to  eat,  some  text   of    Scripture 


Chap.  IV.]  Treatment  of  Hysterical  Patients.  85 

influencing  her  conduct,  and,  from  sheer  inability  to 
keep  her  alive  otherwise,  it  may  be  necessary  to  send 
her  to  an  asylum.  As  a  rule  such  cases  should  be 
tried  in  every  way  possible  at  home ;  for  although  I 
believe  the  discipline  and  treatment  of  an  asylum  are 
extremely  useful  in  such  cases,  yet  the  present  feeling- 
is  that  to  have  been  in  an  asylum  is  a  stain  upon  one's 
character,  and  so  for  a  young  girl  it  is  as  well  to  do 
one's  best  before  trying  this  last  resource. 

Food,  warmth,  exercise,  and  absence  of  friends  are 
the  first  essentials,  and  next  the  ovarian  or  uterine 
trouble  must  be  attended  to.  And  here  I  would  say 
that  it  is  dangerous  to  have  much  done  in  the  way  of 
physical  examination.  If  it  be  found  that  there  is 
tenderness  about  the  ovaries,  a  blister  or  leeches 
may  be  applied,  in  the  inguinal  regions,  and  the 
patient  kept  in  bed  for  a  short  time,  ■  Dry  cupping- 
may  be  of  service  sometimes.  Bed,  however,  is 
distinctly  to  bo  avoided  as  soon  as  any  acute  trouble 
has  passed,  for  the  characteristic  of  all  hysterical 
cases  is  the  tendency  to  laziness,  want  of  will,  and 
getting  into  bad  habits.  If  it  be  necessary  to  feed 
a  patient,  it  is  well  that  it  should  be  done  with  as 
little  fuss  and  as  much  firmness  as  possible,  the  food 
being  administered  either  by  nose,  by  stomach-pump, 
or  sometimes  by  rectum.  In  my  experience  I  have 
found  it  well  to  vary  the  modes  of  feeding,  so  that  the 
danger  of  getting  into  a  habit  is  avoided.  I  have 
known  a  girl  who  required  feeding-  in  consequence  of 
her  weak  physical  condition,  who  became  stout,  and 
apparently  in  good  physical  health,  yet,  having  been 
fed  three  times  daily  with  beef-tea,  wine,  and  similar 
foods,  declined  to  assist  herself  in  any  way,  and  even 
rudely  said  to  the  doctors,  "  I  know  you  must  feed  me, 
and  I  like  giving  you  the  bother."  The  proper  treat- 
ment of  such  a  girl  is  to  give  a  warning  that  now  she 
is  strong  she  will  not  require  feeding,  and  for  the  next 


86        Insanity  and  Allied  Neuroses.    [Chap.  iv. 

few  clays  she  may  take  or  leave  her  food  as  she  likes, 
and  the  chances  are  that  after  a  severe  hysterical  storm 
she  will  take  her  food,  and  the  habit  will  have  been 
broken  once  for  all.  In  some  of  these  cases  a  liberal 
addition  of  salt  to  the  beef-tea  will  create  a  thirst, 
which  will  cause  the  patient  to  take  fluid  food  left  in 
her  way,  and  thus  again  the  habit  may  be  broken. 

Besides  the  refusal  of  food  in  these  cases,  neglect  of 
personal  cleanliness  is  one  of  the  most  troublesome 
symptoms.  I  remember  the  time  when  the  distinction 
between  hysterical  paralysis  and  ordinary  paralysis 
was  considered  to  consist  in  the  fact  that  the  former  did 
not  foul  their  beds  or  clothes,  whereas  the  latter  could 
not  help  themselves  j  but  now  I  look  on  any  such 
dogma  as  worthless.  For  one  sees  many  hysterical 
cases  who  are  filthily  dirty  in  their  habits.  So  far, 
then,  I  think  I  have  established  the  fact  that  these  are 
cases  which  are  distinctly  hysterical,  and  yet  which 
require  to  be  sent  to  an  asylum ;  in  many  such  cases 
hospital  treatment  has  failed.  I  am,  however,  quite 
unprepared  to  say  what  the  direct  brain  causation  may 
be.  It  has  to  be  looked  upon  as  functional  distur- 
bance, for  lack  of  better  knowledge. 

Constantly  cases  are  seen  in  hospitals  and  in 
private  life  in  which  grave  hysterical  symptoms  have 
been  but  the  precursor  of  some  general  physical  break- 
down, ending  in  death.  There  are,  on  the  other  hand, 
cases  of  comparatively  coarse  brain  disease,  in  whicli 
the  only  symptoms  have  been  hysterical.  I  have  seen 
the  fost-mortem  examinations  of  several  cases  iii 
which  slight  symptoms  (all  of  which  were  referred  to 
hysteria)  were  the  only  clinical  evidences  of  serious 
disease  in  the  anterior  lobes  of  the  brain.  In  one 
there  was  adhesion  between  the  two  first  frontal  lobes, 
and  in  the  second  there  was  a  firm  condition  of  the 
whole  of  both  frontal  lobes,  associated  with  a  general 
fibrous   excess.     It  does  not  follow  that  because   in 


Chap.  IV.]  HvSTERO-EpILEPSV.  87 

these  two  cases  the  frontal  lobes  were  alone  affected 
that  hysteria  is  the  natural  outcome  of  disease  of  these 
areas.  Such  disease  may  in  some  way  upset  the 
balance  or  withdraw  the  control,  and  the  result  may- 
be what  we  see,  for  hysteria,  in  many  cases,  may  well 
be  looked  upon  as  an  unrestrained  exercise  of  the  lower 
parts  of  the  human  organisation.  Alterations  in  the 
anterior  lobes  alone  will  not  produce  hysteria.  I  have 
seen  diseases  in  this  region  sometimes  producing 
absolutely  no  traceable  clinical  symptom,  or  setting 
up  epilepsy  or  some  allied  condition. 

Hysteria  usually  occurs  in  women,  but  I  have  seen 
grave  hysteria  in  young  men ;  and  though  I  have 
never  met  with  true  hemi-ansesthesia  and  paraplegia 
in  hysterical  young  men,  yet  I  have  seen  some  cases 
of  globus  hystericus,  so  that  the  man  passed  from  the 
condition  of  the  hysterical  girl  into  that  of  the  hypo- 
chondriacal man. 

Hysteria  may  colour  other  mental  affections  ;  that 
is,  an  exaggeration  of  any  one  of  the  perversions  seen 
in  hysteria  may  become  a  delusion.  Thus,  I  am  in  the 
habit  of  regarding  many  of  the  pains  and  feelings  of 
distress  and  anxiety,  which  are  referred  by  the  patients 
to  their  throats,  to  an  exaggeration  of  the  ordinary 
hysterical  conditions,  in  the  same  way  as  I  would 
interpret  the  false  statements  made  by  those  patients 
that  they  had  been  raped,  to  an  explanation  of  uneasy, 
unsatisfied  feelings  originating  from  the  reproductive 
organs. 

Hystero-epilepsy. — Besides  the  cases  of  simple, 
but  grave,  hysteria  which  have  already  been  con- 
sidered, others  are  admitted  into  asylums,  in  which 
the  convulsive  symptoms  are  those  which  call  for  most 
attention ;  cases,  in.  fact,  of  hystero-epilepsy.  I  have 
had  two  such  cases  in  Bethlem ;  one  in  a  man,  who  was 
conscious  throughout  the  whole  epileptic  seizure,  the 
other  in  a  woman,  who  professed  entire  unconsciousness. 


88        Insanity  and  Allied  Neuroses.    [Chap.  iv. 

This  latter  was  a  single  woman  aged  twenty-five, 
a  dressmaker,  with  no  history  of  insanity.  She  had 
suffered  from  hysteria,  and  had  been  for  a  time  cata- 
leptic, and  was  sent  to  a  hospital  for  the  treatment 
of  her  nervous  disorder.  She  was  transferred  to 
Bethlem  because  she  became  destructive,  was  sleepless, 
and,  at  times,  dangerous ;  she  was  always  worse  about 
the  time  of  her  menstrual  periods.  After  admission 
she  was  quiet  for  nearly  two  months,  then  she  had  a 
severe  fit ;  for  a  time  she  was  cataleptic,  then  suddenly 
'5prang  on  the  attendant,  knocked  her  down,  and  be- 
laboured her  severely.  After  this  she  became  con- 
vulsed, but  there  was  an  organisation  in  the  convulsive 
movements  which  was  very  striking,  so  that,  at  one 
time,  she  would  grasp  at  an  object  within  her  reach, 
and  at  another  time  her  convulsions  would  be  in 
harmony  with  a  tune  that  happened  to  be  played  on 
the  piano  at  the  time,  her  hands  keeping  time  to  the 
music  ;  in  her  convulsions  she  bit  anyone  who  came 
near  her,  or  pulled  their  hair.  At  the  time  of  the 
attack  her  pupils  were  contracted,  and  the  conjunctiva 
less  sensitive  than  normal.  She  had  a  most  marvel- 
lous power  of  keeping  her  eyes  open  without  winking, 
so  that  with  the  ophthalmoscope  I  watched  the 
condition  of  her  disc  for  over  half  an  hour,  during 
which  time  she  never  winked.  The  day  after  the  fit 
she  denied  any  recollection  of  what  had  happened,  but 
complained  of  exhaustion.  When  in  a  fit  she  was 
placed  either  in  a  wet  or  dry  pack,  and  later,  with  the 
onset  of  each  fit,  she  was  put  into  seclusion.  When 
nearly  well,  domestic  grief  caused  her  to  have  a 
relapse,  from  which  she  ultimately  recovered,  was  dis- 
charged well,  and  has  for  years  maintained  herself. 

With  both  the  hysterical  and  hystero- epileptic  a 
grave  responsibility  is  incurred  from  their  violence, 
though  this  violence  is  more  frequently  that  of  the 
tongue  than  of  any  other  more  dangerous  member.  Yet 


Chap.  IV.]  Insanity  of  Limbs.  89 

friends  will  come  in  great  alarm  to  know  what  is  to 
be  done  with  a  young  woman  who  either  impulsively 
knocks  her  relatives  about,  or  who  threatens  suicide. 

A  large  proportion  of  these  hysterical  cases  at  the 
period  of  the  emotional  storms  will  say  they  will  go 
and  kill  themselves,  and  occasionally  they  undoubtedly 
do  attempt  suicide.  It  is  rarely  necessary  to  send  a 
girl  to  an  asylum  simply  because  she  threatens  to  kill 
herself  \  I  believe  very  few  would  do  it  under  any  cir- 
cumstances, and  such  cases  as  these,  by  judicious 
supervision,  may  be  quite  as  well  treated  at  home  as 
in  an  asylum. 

In  the  first  chapter  I  said  that  madness  was  not 
confined  to  the  intellect  and  understanding  alone,  but 
that  there  might  be  insanity  of  a  limb  or  of  a  stomach ; 
that,  in  fact,  there  are  cases  in  which  disordered 
nervous  function  is  exhibited  by  some  motor  or 
visceral  disturbance.  One  hears  periodically  of  cases 
of  insane  arms,  cases  in  which  malleation,  as  it  has 
been  called,  is  carried  on,  the  patient  moving  his  arm 
up  and  down,  as  if  using  a  hammer,  hour  after  hour, 
at  the  rate  of  forty  or  fifty  strokes  a  minute,  antl 
continuing  the  exhausting  process  for  hours.  Some 
such  cases  I  have  seen  pass  the  borderland  of  hysteria, 
and  claimed  as  belonging  to  insanity.  With  the 
insane  stomach  the  same  holds  good.  Patients  may 
emaciate,  and  be  reduced  most  rapidly  to  mere  skele- 
tons through  gastric  disturbance  associated  with 
hysteria.  I  have  known  cases  of  people  who  appeared 
to  vomit  everything  that  was  given  them  for  weeks  ; 
the  vomiting  was  hysterical,  and  the  exhaustion  pro- 
duced thereby  was  sufficient  to  turn  the  scale,  and 
send  the  girl  into  an  asylum. 

With  all  the  symptoms  that  have  been  described 
associated  with  hysteria,  hystero-epilepsy,  and  hys- 
terical insanity,  so  called,  there  may  be,  and  generally 
is,  perversion  of  the  functions  of  the  ovaries.     There 


90        Insanity  and  Allied  Neuroses.    [Chap.  iv. 

may  be  amenorrhoea,  dysmenorrhoea,  or  menorrhagia, 
and  with  these  physical  disorders  there  may  be 
marked  eroto-mania  and  tendency  to  masturbation. 

Newrastlieiiia.— I  cannot  close  this  subject  with- 
out referiing  to  the  Weir-Mitchell  treatment  of  the 
so-called  neurasthenic  cases  which  Dr.  Playfair  has 
so  fully  introduced  into  England.  Patients  who 
have  slowly  become  chronic  invalids  have  been  by 
this  method  brought  back  not  only  to  life  but  to 
active  usefulness.  The  history  and  treatment  of  a 
case  is  as  follows.  A  woman,  generally  single,  or  in 
some  way  not  in  a  condition  for  performing  her 
reproductive  function,  having  suffered  from  some  real 
or  imagined  trouble,  or  having  passed  through  a  phase 
of  hypochondriasis,  chiefly  affecting  her  uterus  or 
ovaries,  and  often  being  of  a  highly  nervous  stock, 
becomes  the  interesting  invalid.  She  is  surrounded 
by  good  and  generally  religious  and  sympathetic 
friends.  She  is  pamjDered  in  eveiy  way.  She  may 
have  lost  her  voice,  or  the  power  of  one  limb.  These 
temporary  paralyses  often  pass  off  suddenly  with  a 
new  doctor  or  a  new  drug ;  but,  as  a  rule,  they  are 
replaced  by  some  new  neurosis.  In  the  end  the 
patient  becomes  bed-ridden,  often  refuses  her  food,  or 
is  capricious  about  it,  taking  strange  things  at  odd 
times,  or  pretending  to  starve.  Masturbation  is  not 
uncommon.  The  body  wastes,  and  the  face  has  the 
thin  anxious  look,  not  unlike  that  represented  by 
Rosetti  in  many  of  his  pictures  of  women.  There  is 
a  hungry  look  about  them  which  is  striking.  With 
the  wasting,  real  loss  of  power  follows.  The  patients 
must  not  be  accused  of  malingering  when  they  say 
they  cannot  walk  or  sit  up.  If  not  vigorously  treated 
they  will  die.  In  treating  such  a  case  the  following 
principles  must  be  observed.  Removal  of  the  patient 
absolutely  from  all  friends,  and  the  personal  supervi- 
sion, in  all  but  solitary  confinement,  of  the  patient  by 


Chap.  IV.]  Hysterical  Mania.  91 

the  skilled  nurse.  The  "massage"  is  performed  in  a 
way  resembling  shampooing,  twice  daily,  beginning 
with  half  an  hour  at  a  time,  and  gradually  ex- 
tending to  two  or  two  and  a  half  hours  twice 
daily.  Milk  in  half-pint  quantities  must  be  given 
every  hour  or  two  hours,  and  strong  beef-tea  in 
similar  quantities  in  the  morning  and  afternoon.  The 
muscles  of  the  trunk  and  extremities  must  be  not 
only  individually  rubbed,  but  also  daily  stimulated 
by  electricity.  It  will  soon  be  found  that,  under  this 
treatment,  patients  will  develop  ravenous  appetites, 
and  will  take  three  full  meat-meals  daily,  besides  the 
milk  and  beef-tea.  Stimulants  should  be  given  with 
the  meals. 

Dr.  Sharkey,  of  St.  Thomas's  Hospital,  has  told 
me  of  cases,  who,  after  years  of  bed-ridden  weak- 
ness, have  been  able  to  take  horse  exercise  within 
three  months ;  and  of  others  in  whom  the  gain 
in  weight  has  been  nearly  one  pound  daily.  In  one 
of  his  cases,  a  woman  of  twenty-nine  years  of  age 
weighed  only  four  stone  two  pounds,  and  yet  within 
a  few  months  became  stout  and  strona;.  If  this 
treatment  is  to  be  followed,  no  half  measures  must  be 
taken.  Removal,  seclusion,  massage,  and  feeding, 
are  the  means  of  cure,  and  they  must  be  made  use 
of  not  separately,  but  all  combined. 

Mysterics&l  maiila,  acute  delii'ious  mania, 
typlio- mania.— From  the  study  of  hysteria  and 
hysterical  disturbances,  one  naturally  passes  to  the 
consideration  of  mania  in  which  there  is  marked 
emotional  disturbance ;  and  first  I  shall  refer  to  cases 
of  acute  delirious  mania,  or  what  has  generally  been 
called  "brain  fever."  This  disorder  has  many  dis- 
tinct points  of  difference  from  acute  mania ;  and 
from  the  extreme  danger  to  life  which  arises  from  it, 
it  requires  a  special  and  detailed  study. 

Before  entering  fully  on  its  study  and  description, 


92        Insanity  and  Allied  Neuroses.    [Chap.  iv. 

I  shall  point  out  the  chief  characteristics  of  ordi- 
nary mania,  so  that  the  differences  between  ordinary 
mania  and  delirious  mania  may  appear. 

Mania,  is  most  common  in  those  with  a  neurotic 
inheritance,  but  may  occur  in  persons  with  no  such 
history.  It  is  generally  preceded  by  a  period  of 
depression,  which  may  either  suddenly  or  gradually 
pass  away,  to  be  succeeded  by  excitement,  the  chief 
characteristics  of  which  are  restlessness  with  tendency 
to  violence  ;  the  ideas  seem  to  flow  along  certain  lines 
more  rapidly  than  in  health,  and  the  associations, 
verbal  and  otherwise,  though  somewhat  hard  to  follow 
from  the  rapidity  of  their  formation,  are  yet  traceable, 
if  the  sense  impressions  are  noticed.  Memory  may  be 
perfect,  or,  although  not  lost,  altered,  so  that  the  past 
is  left  with  an  irregular  outline.  Will  is  unstable, 
and  the  emotional  side  of  the  individual  is  less  re- 
strained, so  that  there  is  a  tendency  to  excesses  of 
one  kind  or  another.  Ordinarily  all  these  changes 
are  connected  with  but  little  alteration  in  the  physical 
appearance  at  first.  The  body  temperature  is  gene- 
rally normal,  the  appetite  is  capricious,  the  tongue 
furred  or  foul,  and  the  bowels  confined  ;  the  symp- 
toms frequently  become  worse  towards  night,  there 
being  almost  always  marked  sleeplessness.  E-ecovery 
is  frequent. 

In  acute  delirious  mania  there  is  frequently  insane 
inheritance ;  the  outbreak  of  insanity  is  often  sudden, 
or  the  transition  from  indolence  or  melancholy  to 
mania  is  sudden  ;  the  maniacal  outbreak  generally  has 
some  definite  cause,  and  may  suddenly  follow  on  a 
shock,  a  grief,  or  on  some  physical  disease,  such  as  a 
pneumonia  or  a  fever.  The  patient  is  more  restless 
than  in  ordinary  mania,  and  the  sleeplessness  is 
more  constant ;  the  language  is  more  incoherent,  and 
resembles  the  talk  of  a  patient  in  the  height  of  a 
fever,   for   though   attention    may  be   recalled  for  a 


Chap.  IV.]         Acute  Delirious  Mania.  93 

moment,  no  continuous  trains  of  thought  are  started 
by  sense  impressions  from  without. 

Early  in  the  disease  the  temperature  is  raised, 
ranging  from  100^  in  the  morning  to  102*^  at  night. 
The  face  is  often  flushed,  the  pulse  small  and  rapid, 
respiration  may  be  rapid  or  sighing. 

The  patient,  if  extremely  ill,  will  lie  on  the  back 
muttering.  The  lips  are  covered  with  dry  brown 
sordes,  and  the  tongue  is  dry,  cracked,  and  leathery. 
All  food  is  refused,  there  appearing  to  be  great 
pain  in  swallowing  ;  bowels  obstinate  and  confined. 
There  is  no  rash  and  no  sweating.  Masturbation 
is  common ;  urine  and  faeces  passed  involuntarily. 

Bed-sores  rapidly  form.  The  patient  quickly 
wastes,  and  may  die  in  a  few  days,  or  may  pass  into 
a  condition  of  profound  physical  weakness  associated 
with  mental  torpor ;  there  may  be  some  paraplegia 
or  contraction  of  the  lower  extremities.  The  memory 
is  either  wanting,  or  greatly  affected.  Recovery  may 
take  place,  and  in  some  cases  years  have  passed 
without  any  relapse.  The  rapid  exhaustion,  the 
increased  temperature,  the  delirious  chatter,  and  hal- 
lucinations of  the  senses,  especially  of  sight  of  a 
transient  nature,  and  the  frequently  fatal  issue, 
distinguish  this  disease. 

Acute  delirious  mania.  Acute  mania. 

Cause  often  definite.  Cause  doubtful. 

Onset  often  sudden,     [creased.        Onset  gradual. 

Temperatxire    considerably    in-       Tem^Derature  nearly  normal. 

Kefusal  of  food.  Appetite  capricious. 

Rapid  wasting  with  weakness.  "Wasting  much  less. 

Flushed  face.  Pale  or  sallow  complexion. 

Hallucinations,  variable  and  Hallucinations  more  persistent 
like  those  of  fever.  if  present. 

Greater  incoherence  of  speech.        Incoherence     associated     with 

sense  impressions. 

;JVIemory  often  wanting.  Memory     present,     often     in- 

fluenced by  the  surround- 
ings. 

Result  often  fatal.  Results  mostly  favourable. 


94        Insanity  and  Allied  Neuroses.    [Chap.  iv. 

A.  case  such  as  the  following  is  a  good  example. 
A  woman  thirty  years  of  age,  having  no  neurotic 
inheritance,  but  with  a  delicate  mother,  fell  out 
of  health  and  became  sleepless  and  nervous ;  no 
history  of  love-disappointment  or  injury  could  be 
obtained ;  there  had  been  loss  of  flesh  with  irre- 
gularity in  menstruation ;  her  appetite  was  capri- 
cious, and  she  was  considered  by  her  friends  to 
be  giving  way  to  whims  and  fancies  ;  she  was,  in 
fact,  becoming  troublesome  and  hard  to  manage. 
Change  of  scene  was  tried,  and  followed  by  temporary 
improvement,  yet,  on  the  whole,  the  patient  w^as  below 
par.  A  fright,  of  no  extreme  severity,  caused  a  sleep- 
less and  disturbed  night,  followed  by  further  de- 
velopment of  restlessness.  She  became  loquacious 
and  rather  incoherent,  or  perhaps  it  would  be  better 
to  say,  silly  in  her  way  of  talking.  She  then  became 
less  careful  about  her  dress  and  appearance,  got  up  at 
night  and  removed  her  night-dress,  and  would  have 
walked  about  nude.  After  this  there  was  a  develop- 
ment of  sexual  desire.  She  spoke  of  being  married, 
and  her  habits  became  dirty  and  offensive.  Food  was 
refused,  and  she  rapidly  lost  strength  ;  all  endeavours 
to  support  her  general  health  failed,  and  night  after 
night  she  was  restless,  unless  subdued  by  strong 
narcotics.  Nutrient  enemata  and  feeding  by  nose  and 
by  stomach  pump  were  tried,  but  with  little  good 
effect,  and  notwithstanding  every  endeavour,  the 
patient  lost  weight  rapidly  and  sank,  having  become 
partly  conscious  before  death.  During  the  whole 
period  the  temperature  had  been  high. 

In  another  case  a  very  similar  history  was  given, 
the  chief  point  of  interest  being  that  this  young 
woman  had  high  temperature  for  some  weeks  before 
it  was  considered  necessary  to  send  her  away  from 
home.  The  reasons  for  having  removed  her  were 
that  she  refused  food,  was  wet  and  dirty,  had  also 


Chap.  IV.]         Acute  Delirious  Mania.  €,5 

habits  of  self-abuse  which  could  not  easily  be  con- 
trolled, and  which  were  getting  fixed.  She  was  sent 
to  a  general  hospital,  but  here  she  was  so  violent  in 
her  language  and  in  her  opposition  to  certain  of 
the  nurses,  that  it  was  found  impossible  to  keep 
her  there.  She  was  transferred  to  Bethlem  in  a 
very  weak  condition.  Her  lower  limbs  were  mere 
skeletons,  and  there  were  bed-sores  on  both  hips 
and  over  the  sacrum,  the  legs  being  contracted,  while 
any  attempt  to  move  them  was  followed  by  a 
violent  emotional  outburst.  Food  was  taken  very 
badly,  and  it  was  with  difficulty  that  she  could  be 
persuaded  to  take  sufficient.  A  steady  insistance, 
however,  in  the  taking  of  food  with  an  abundance  of 
stimulants,  was  followed  by  good  results,  so  that  her 
legs  became  stronger,  she  was  able  to  walk,  the  loss 
of  power  over  bladder  and  rectum  disappeared,  bed- 
sores healed,  and  the  whole  of  the  emotional  disorder 
passed  away,  and  in  the  end  the  patient  was  cured 
after  eight  months'  treatment. 

Acute  hysterical  mental  disorder  of  a  melan- 
choly ty^e. — Edith  S.,  single,  22,  sister  an  idiot, 
maternal  uncle  insane,  maternal  aunt  insane.  She 
was  a  somnambulist  as  a  child;  had  chorea  when  11 
years  old  ;  has  been  subject  to  neuralgic  headaches  ; 
she  was  admitted  into  a  general  hospital  on  February 
4th,  1884,  and  was  considered  to  be  suffering  from 
grave  hysteria.  The  attack  was  the  result  of  loss 
of  relations  by  death,  and  change  in  her  social  posi- 
tion. She  refused  food,  passed  her  urine  and  faeces  in 
bed.  Her  temperature  was  raised,  there  was  a  dry 
brown  tongue,  foul  breath  and  great  and  rapid  ema- 
ciation. She  was  sleepless,  at  times  excited,  emotional, 
and  incoherent ;  had  hallucinations  of  sight ;  some  loss 
of  common  sensibility  of  left  arm,  and  tenderness  over 
left  ovary.  There  was  later  noticed  to  be  some  con- 
fusion about  greens  and  pinks,  her  memory  was  fourd 


96         Insanity  and  Allied  Neuroses.   [Chap.  iv. 

to  be  defective.  The  patient  was  removed  to  Beth- 
lem  ;  there  she  was  constantly  and  persistently  fed 
with  nourishing  and  stimulating  food.  She  resisted 
for  a  time.  Within  a  month  of  her  admission  she 
w^as  mentally  w^ell,  though  very  weak.  She  will  keep 
well  for  a  time  at  all  events^  but  with  such  a  history 
of  nervous  disease  in  the  family  we  must  expect 
lelapses. 

1  have  seen  other  cases  recover,  in  which  the  chief 
symptoms  were  the  delirious  excitement  and  persistent 
high  temperature,  the  refusal  to  take  food,  dry  brown 
tongue,  constipation,  fulness  or  tenderness  of  the 
abdomen,  rapidly  succeeded  by  emaciation,  contraction 
of  the  lower  limbs,  and  development  of  huge  bed- 
sores. These  cases  have  generally  occurred  in  women, 
and  have  almost  always  been  associated  with  some 
ovarian  excitement.  They  fall  under  the  head  of 
what  has  been  called  typho-mania,  and  are  of  extreme 
interest  to  the  general  pathologist ;  for  though  these 
j)atients  seem  to  have  a  disease  of  an  inflammatory 
nature,  yet  we  have  hitherto  failed  to  find  the  sources 
of  the  disorder.  I  have  made  post-mortems  on  such 
cases,  in  which  it  was  impossible  to  detect  coarse 
disease  of  any  kind  whatever;  and  on  examining 
the  brain  of  one  case,  I  have  found  the  vessels 
congested,  and  in  that  of  another  I  have  found  them 
empty. 

In  several  cases  there  have  been  found  changes 
or  diseases  in  some  distant  organ.  Thus,  in  a  pa- 
tient who  died  in  Bethlem,  besides  some  fulness  of 
the  intracranial  vessels,  an  ovarian  cyst,  in  a  con- 
dition of  inflammation,  was  found;  and  in  another 
elderly  woman,  who  died  in  a  similar  condition,  there 
was  found  a  series  of  abscesses  about  the  uterus. 
The  chief  point  of  interest  in  these  cases,  from  the 
clinical  side,  is  the  high  temperature.  There  is  no 
great  variation  in  the  range,  but  one  usually  finds  the 


Chap.  IV.] 


Food. 


97 


niglit  temperature  the  higher,  and  this  is  from  100° 
to  102°.  I  have  no  explanation  to  give  of  this,  for 
we  are  totally  ignorant  of  any  brain  centre  which  has 
a  special  controlling  influence  over  the  heat-producing 
function.  In  these  cases  the  heart  and  lungs  appear 
to  be  healthy.  From  the  side  of  treatment  which  in 
these  cases,  to  my  mind,  is  of  infinite  importance,  I 


Temperature  of  a  case  of  Acute  Delirious  Mania. 


would  recommend  the  early  administration  of  abun- 
dant easily  assimilated  food,  and  that  no  feeling  of 
sentiment  should  withhold  the  physician  from  feeding 
artificially.  I  should  feed  such  a  patient  every  three 
hours,  night  and  day,  with  half-a-pint  of  fluid  food, 
letting  her  have  milk  with  an  %gg,  milk  thickened 
with  arrowroot,  beef-tea,  mutton-broth  with  one  or 
other  of  the  meat  extracts,  and  with  each  meal  I 
would  give  some  stimulant  equal  to  about  one  half- 
ounce  of  brandy.  The  idea  that  in  such  cases  brandy 
or  spirits  of  any  kind  will  affect  the  brain  inj  uri  ously 
is  a  mistake,  and  many  a  sleepless  patient  would  rest 
H— 14 


98  Insanity  and  Allied  N'ex/roses.   [Chap.  iv. 

after  a  night-cap  of  port- wine  negus  or  a  bottle  of 
porter,  who  is  otherwise  restless.  Food,  then,  is  the 
first  consideration. 

If  the  patient  is  to  be  treated  at  home,  it  will  be 
almost  certainly  necessary  that  she  should  have  some 
form  of  sedative.  Bromide  of  potassium,  in  some 
cases,  seems  to  be  specially  indicated,  its  supposed 
effect  in  suppressing  sexual  desire  making  it  useful. 
In  some  cases  I  have  given  half- drachm  doses  of 
bromide  of  potassium  as  eneraata,  by  this  means 
succeeding  in  calming  the  irritability  of  the  mucous 
membrane  of  the  vagina ;  and,  if  seen  sufficiently 
early,  before  there  is  much  weakness,  these  cases  may 
be  benefited  by  baths  of  from  98°  to  120°;  the  higher 
the  temperature  the  shorter  the  time  the  patient  must 
be  retained  in  the  water.  I  have  frequently  pre- 
scribed a  bath  of  100°  night  and  morning,  each  of  one 
hour's  duration.  Chloral  may  be  given  with  the 
bromide  of  potassium,  or  alone,  in  doses  not  exceeding 
thirty  grains  to  begin  with.  I,  personally,  do  not 
like  chloral  in  these  cases,  for  many  reasons,  one 
being  that  it  has  a  tendency  to  make  patients,  who 
are  still  taking  their  food,  suspicious  and  inclined  to 
refuse  it.  Occasionally  I  have  given  chloral  and 
brandy  combined  in  some  extremely  weak  cases,  and 
with  considerable  benefit.  I  have  failed  to  see  good 
results  from  local  or  general  counter-irritation,  or  by 
the  application  of  ice  to  the  head.  I  should,  however, 
add,  that  some  physicians  of  large  experience  believe 
that  in  chloral  they  have  a  means  to  combat  this 
ilisease. 

From  what  we  have  seen  it  will  be  clear  that  the 
diagnosis  of  this  disease  may  be  difficult.  The  chief 
diseases  for  which  it  may  be  mistaken  are  typhoid 
fever,  meningitis,  the  later  stages  of  some  febrile 
disease,  such  as  rheumatism  with  hyper- pyrexia  ;  but 
in  this  disease  there  is  rarely,  or  never,  intolerance  of 


Chap,  v.]  Acute  Mania. 


99 


light,  or  complaints  of  pains  in  the  head,  or  vomiting, 
thus  separating  it  from  meningitis ;  and  that  there 
is  no  tendency  to  diarrhoea,  no  enlargement  or 
tenderness  of  the  abdomen,  would  separate  it  from 
typhoid  fever.  The  disease  may  kill,  and,  as  I  have 
said,  is  a  much  more  fatal  malady  than  ordinary 
acute  mania.  Patients  may  get  well,  or  they  may 
pass  into  a  condition  of  weak-mindedness  after  tiie 
acute  attack.  I  have,  however,  never  seen  a  case 
suflfering  twice  from  this  condition  ;  for  though,  as  I 
have  said,  I  have  seen  cases  suffering  from  some  form 
of  insanity  with  a  history  of  brain  fever  before,  yet 
I  have  never  come  across  a  patient  with  a  relapse  of 
delirious  mania.  There  is  a  great  tendency  in  patients 
who  suffer  from  this  condition,  if  they  do  not  recover, 
to  pass  into  a  state  of  chronic  weak-mindedness  with 
excitement ;  they  will  suffer  from  general  incoherence, 
and  may  live  for  years. 


CHAPTER    Y. 

ACUTE    MANIA. 

Maniacal  conditions— ]\fania  as  a  stage  in  ment.il  disorder — Bodily 
symptoms  —  Mental  symptoms  —  Course  and  varieties  — 
Eesults. 

This  is  a  form  of  mental  disorder  of  variable  intensity 
and  duration,  in  whi(;h  loss  of  control  of  the  various 
constituents  of  mind  is  the  most  marked  character- 
istic. No  more  precise  definition  will  cover  all  the 
cases  I  shall  have  to  consider  in  this  group. 

Acute  mania. — 1.  May  be  the  whole  of  the 
disordered  process. 

2.   Or  part  of  a  more  complex  form  of  insanity. 


100         Insanity  AND  Allied  Neuroses.    [Chap.  v. 

Thus  it  may  be  a  stage  in  recurrent  mania,   or  in 
folie  circulaire. 

3.  It  may  be  a  symptom  of  a  more  serious  disease, 
such  as  general  paralysis  of  the  insane. 

4.  It  may  be  a  concomitant  of  epilepsy  following 
or  replacing  a  fit. 

5.  Or  it  may  be  the  further  development  of  a 
delirium  due  to  fever  or  alcohol. 

6.  It  may  replace  some  other  neurosis,  such  as 
asthma  or  hysteria. 

General  s^inptoius  of  mania.  Bodily 
symptoms. — In  acute  mania  the  patient  generally 
loses  flesh,  the  circulation  is  weak,  so  that  pulse  trac- 
ings are  often  very  feeble,  the  complexion  sallow, 
tongiie  slightly  tremulous,  flabby,  and  with  a  tendency 
to  white  fur,  breath  often  rather  foul,  aj^petite  at  first 
impaired,  becomes  variable,  capricious,  and  unnatural, 
and  may  later,  if  the  patient  be  passing  into  a  more 
chronic  state,  become  almost  insatiable.  The  bowels 
are  usually  confined,  the  urine  is  normal  as  to  con- 
stituents^ but  may  be  diminished  in  quantity,  or 
occasionally,  in  some  of  the  slighter  cases  allied  to 
hysteria,  it  may  be  of  low  specific  gravity  and  abun- 
dant. 

In  women  menstruation  is  generally  absent.  In 
both  sexes  there  is  fi^equently  eroticism.  There  may 
be  loss  of  common  sensibility.  The  patient  is  rest- 
less by  day,  and  sleepless  by  night;  frequently  he 
objects  to  wear  any  clothes,  and  I  have  often  found 
some  change  in  common  sensibility.  Earely  is  there 
hyperaesthesia  ;  more  commonly,  local  or  general  loss 
of  feeling. 

A  good  deal  has  been  said  of  the  aspect  of  the 
maniac,  so  that  he  is  supposed  always  to  have  wild 
staring  eyes,  a  harsh  raucous  voice,  with  a  peculiar 
mousy  smell ;  not  one  of  these  is  characteristic. 
The  eyes  have  nothing  special  in  their  appearance, 


Chap,  v.]  AIental  Symptoms.  loi 

the  pupils  being  dilated  and  sluggish  in  the  majority 
of  young  active  cases,  pointing  to  the  mania  as  a 
condition  of  physical  weakness,  not  one  of  any 
inflammation  of  the  brain  or  its  membranes.  The 
voice  may  be  raucous  from  over-exercise,  and  the 
smell  may  be  mousy  from  constant  sweating,  due  to 
severe  continued  exercise  and  dirty  habits.  The 
hair,  at  times,  assumes  what  has  been  called  an 
electrical  condition.  We  have  had  patients  in 
Bethlem  whose  attacks  of  recurrent  mania  weie 
always  associated  with  the  hair  becoming  stiff,  dry, 
and  wiry  j  and,  undoubtedly,  nutritional  changes  may 
occur  in  each  fresh  attack  of  mania.  The  maniac  is 
generally  credited  with  a  large  amount  of  physical 
power ;  and  although  one  is  now  and  again  astonished 
at  some  feat  of  unusual  strength,  I  have  failed  to 
satisfy  myself  that  there  is  ever  any  unnatural  power 
in  the  patients.  They  may  have  the  appearance  of 
possessing  extra  force  from  the  fact  that  they  have 
often  singleness  of  purpose,  which  concentrates  all 
their  energies  on  one  object;  for,  although  the  acute 
maniac  is,  by  definition,  a  person  weak  of  will,  yet 
we  constantly  meet  with  cases  in  which  either  a 
repetition  of  certain  hallucinations,  or  the  persistence 
of  some  delusion,  acts  as  a  fresh  stimulant  to  exercise 
in  a  fixed  line.  Though  maniacs  are  not  physically 
stronger  than  the  sane,  one  must  admit  in  some  cases 
a  power  of  endurance  which  is  astonishing.  A  weak 
woman,  for  example,  will  day  after  day,  and  night 
after  night,  talk,  scream,  and  gesticulate^  at  the  same 
time  taking  little  or  no  nourishment. 

Mental  symptoms. — Under  bodily  symptoms 
we  have  noticed  the  fact  that  there  may  be  changes 
in  sensibility,  and  this  is  seen  in  different  ways. 
Thus,  a  patient  may  appear  not  to  feel,  being  so  much 
occupied  by  his  delusions  or  by  the  fury  of  his  ex- 
citement ;  but,  in  other  cases,  there  is,  undoubtedly^ 


I02 


Insanity  and  Allied  Neuroses.    [Chap.  v. 


loss  of  feeling  in  parts  of  the  skin^  and  besides  loss  of 
feeling,  probably  perverted  feeling  is  most  common, 
so  that  the  patient  complains  of  itching  or  halluci- 
nations,  imagining   that   people    tear   or   scrape    his 


A  case  of  Simple  Acute  Mania. 


body.  In  several  cases  I  have  seen  hypersesthesia, 
and  in  two  the  patients  fancied  that  their  bodies  had 
swollen  inordinately.  They  gazed  at  their  limbs 
with  horror,  fancying  that  soon  they  would  be  too 
big  to  remain  in  the  house.  In  one  of  these  the 
result  was  great  violence,  because  the  patient  fancied 


Chap,  v.]  Hallucinations.  .  103 

that  lie  would,  by  his  great  bodily  increase,  be  crushed 
to  death,  as  the  walls  of  his  bedroom  would  not 
expand  to  his  necessities.  In  another  case  I  have 
seen  general  tenderness  in  all  the  bones  of  the  body, 
so  that  either  steady  or  sudden  pressure  upon  a  bone 
]:)roduced  shrieking  and  signs  of  pain,  and  this  oc- 
curred whether  the  patient's  attention  were  occupied 
or  not.  He  shrieked  suddenly  if  his  shin  were 
pressed  under  the  bed-clothes. 

Halliicmations.— Although  the  appearance  of 
the  eye-balls  may  be  natural,  every  variety  of  hallu- 
cination and  illusion  may  affect  the  sense  of  sight. 
The  person  suffering  from  delirious  mania  frequently 
sees  spectral  images,  insects,  or  vermin,  very  much 
after  the  fashion  of  the  fever  patient ;  the  acute 
maniac  is  likely  to  be  troublesome  at  night,  from 
hallucinations  of  one  kind  or  another.  He  may  see 
liis  near  relatives,  sparks  and  flashes  of  light,  or  a 
succession  of  figures  like  a  panorama.  The  sights,  as 
a  rule,  are  constantly  changing,  the  condition  of  mania 
being  a  mobile  one. 

Hallucinations  of  hearing  are  common,  the  pa- 
tient hearing  the  voices  of  his  old  comrades,  or 
those  of  his  relations.  Many  of  the  actions  of  the 
acute  maniac  depend  on  the  hallucinations  of  hearing. 
Besides  "  voices,"  there  may  for  some  time  have  been 
sounds,  drummings,  thumpings,  or  ringing  of  bells,  or 
the  repetition  of  musical  notes,  which  may  have  been 
considered  by  the  patient  either  as  communications 
from  his  friends,  or  else  as  things  done  to  annoy  and 
disturb  him  \  so  that,  his  sleep  being  light  at  the  best, 
he  is  convinced  that  these  things  are  done  maliciously, 
and  hence  he  is  embittered  against  those  whom  he 
supposes  to  be  the  instigators  of  the  disturbance. 

Hallucinations  of  taste  and  smell  may  occur,  the 
idea  most  commonly  being  that  some  filthy  or  poison- 
ous gases  are  being  used  to  injure,  or  that  poison  or 


I04         Insanity  AND  Allied  Neuroses.    [Chap.  v. 

filth  is  being  mixed  with  the  food.  Hallucinations 
of  this  kind  may  prevent  the  patient  from  taking 
his  food. 

Next  to  sense  perversions,  I  have  to  refer  more 
fully  to  the  condition  of  the  memory  in  acute  mania. 


A  case  of  Acute  Mania. 


In  the  more  severe  cases  of  delirious  mania,  as  in 
cases  of  acute  primary  dementia  and  cases  of  melan- 
choly with  stupor,  there  may  be  complete  loss  of 
memory,  so  that  the  patient,  after  days  or  weeks  of 
incoherent  noisy  restlessness,  wakes  up  to  find  himself 
in  an  asylum  ',  and  often  is  angry  at  his  situation, 
and  cannot  be  persuaded  that  he  at  any  time  has 


Chap,  v.] 


Memory  in  Acute  Mania. 


105 


required  such  detention.  There  is  in  such  cases  a 
period  of  mental  soreness  after  the  excitement  ]ias 
passed,  in  which  everything  seems  to  affect  the  patient 
painfully,  and  he  looks  upon  the  actions  of  his  friends 


A  case  of  Clii'oiiie  Mania. 


as  injurious  and  unkind.  The  memory  during  the 
attack,  on  the  other  hand,  may  be  slightly  altered  or 
masked,  so  that  the  patient's  condition  is  very  like 
that  which  most  persons  have  experienced  in  dreams, 
a  feeling  of  something  having  happened  which,  at 
'first,  was  difficult  to  recall,  but  which,  when  once  the 
thread  has  been  found,  may  be  readily  followed  up. 


io6         Insanity  and  Allied  Neuroses.    [Chap.  v. 

It  is  well  here  to  recognise  the  fact  that  the  me- 
mories of  some  of  the  emotionally  insane  are  not  trust- 
worthy, and  that  patients  who  have  passed  through 
an  attack  of  insanity  will  often  be  ready  to  give  full 
details  of  their  experiences,  but  these  experiences  are 
not  reliable.  They  develop  romantic  histories  from 
their  inner  consciousness.  The  memory  of  the  at- 
tack may  be,  however,  clear  and  precise,  and  it  is 
well  to  remember  this,  for  patients  are  keenly  alive 
to  what  is  said  of  them  while  they  are  insane.  I 
have  known  them  in  Bethlem  deeply  wounded  by  the 
ignorant  commiseration  of  a  visitor  to  the  wards,  who 
with  all  kindness  has  said,  "  Poor  things  !  how  very 
wretched  it  makes  me  to  see  them  ! "  And  I  have 
had  lessons  myself  when  convalescent  patients  have 
told  me  that  they  remembered  a  somewhat  harsh  ex- 
pression or  thoughtless  word  used  in  reference  to  their 
cases. 

Another  important  point  to  be  noted  concerning 
the  memory  of  persons  suffering  from,  mania  is,  that 
sometimes  there  is  a  kind  of  double  consciousness,  the 
patient's  memory  during  each  recurrence  of  mania 
having  chiefly  to  do  with  the  acts  and  feelings  of  the 
previous  attack  of  insanity.  Thus,  a  patient  who  was 
treated  by  me  with  hyoscyamine  during  a  first  violent 
attack  of  insanity,  took  a  great  dislike  to  me,  in  con- 
sequence, I  believe,  of  the  powerfully  unpleasant 
feelings  produced  by  that  drug.  She  recovered,  and 
for  some  time  was  not  only  passively,  but  actively 
grateful  for  all  the  kindness  shown  her ;  but  no 
sooner  was  she  again,  affected  with  mania  than  she 
returned  to  her  hatred  of  me,  and  her  first  act  on  re- 
admission  was  to  crush  my  hat  over  my  eyes  and 
call  me  "  poisoner."  In  another  case,  a  patient  who 
had  been  three  times  in  Bethlem,  on  each  occasion 
reverted  to  the  injustice  of  his  incarceration,  the 
wickedness  of  asylums,  and  my  specially  sinful  and 


Chap,  v.]    Imagination  Among  THE  Insane.  107 

godless  habits  ;  the  same  man  when  well  being  my 
very  good  friend. 

Imagination.,  probably,  is  the  most  attractive  side 
of  mania.  The  poet,  the  actor,  and  the  artist,  all 
look  upon  the  lunatic  as  an  imaginative  being.  The 
superintendent  of  an  asylum  regards  the  imagination 
of  the  lunatic  in  quite  another  way  :  he  meets  with 
comparatively  little  real  brilliant  imagination.  The 
chief  points  to  be  noticed  are  that  maniacs  do  not 
think  along  strictly  conventional  lines;  that  they 
have  often  lost  all  fear  of  being  thought  odd  or 
singular,  together  with  all  finer  appreciation  of  the 
proprieties  of  society,  and  will  say  things  painful  or 
vulgar  without  compunction.  Thoughts  seem  to  run 
riot,  and  in  the  rapid  flow  of  words  strange  associa- 
tions are  made.  The  imagination  of  the  maniac  is 
undesiafned  and  uncontrolled.  He  lies  idle,  as  it 
were,  and  lets  his  ideas  arrange  themselves  according 
as  they  are  started  by  impressions  made  from  without 
upon  one  sense  or  another.  The  aspect  of  the  patient 
points  at  times  to  a  state  allied  to  poetic  ecstacy, 
and  after  recovery  strange  dream -like  experiences 
may  be  obtained  from  some  patients. 

Connected  with  this  subject  is  the  one  of  rapid 
verbal  association,  punning,  and  verse-making.  In 
mania  one  is  able  to  trace  the  way  in  which  ideas  and 
words  are  linked  together  in  the  mind  ;  in  fact,  the 
study  of  speech,  in  acute  mania,  teaches  much  about 
the  mode  of  association  of  ideas.  There  are  two 
distinct  methods  of  combination,  the  verbal  and  the 
ideational,  so  that  one  patient,  hearing  a  tinkle  of  a 
bell,  at  once  begins  rhyming  with  words  like  bell, 
tell,  fell,  knell,  and  hell.  Another,  seeing  a  ring 
upon  one's  finger,  rapidly  passes  from  ring  to  fling 
and  sing,  with  many  more  verbal  associations. 
But  another  way  of  association  is  by  similarity  of 
ideas,    so   that  a   person's   name   suggesting    a   fish, 


io8         Insanity  and  Allied  Neuroses.    [Chap.  v. 

the  patient  rapidly  passes  from  whelks  to  oysters, 
shell-fish,  garden-snails,  and  fishery  exhibitions.  Pro- 
bably the  most  common  is  to  have  a  combination  of 
both  methods,  as  when  a  woman,  seeing  a  hat,  in- 
stantly said  cat,  mouse-trap,  kittens,  the  association 
being  first  hat  and  cat  verbal,  and  next  mouse-trap 
and  kittens,  ideational. 

It  would  be  wrong  to  say  we  do  not  meet  with 
poetic  imagination  among  the  acutely  maniacal.  Eor 
example,  a  patient  who  associated  all  her  ideas  of 
moral  qualities  with  colour  was  brilliantly  imagi- 
native. Everything  that  was  good  and  jDure  was 
white  and  upright  or  straight,  perfection  to  her  mind 
being  a  square  of  perfect  whiteness.  Unfortunately 
slie  looked  upon  me  as  a  black  round.  She  was 
consistent  in  all  her  speech,  and  hardly  ever  made  a 
mistake  when  qualifying  acts  by  means  of  the  use 
of  colour.  Occasionally  patients  are  given  to  imagi- 
native drawing,  while  others  produce  verses  by  the 
hundred ;  but,  generally,  both  drawing  and  poetry 
are  very  bad. 

The  consideration  of  imagination  and  of  the 
rapid  but  altered  association  of  ideas  naturally 
leads  me  to  what  is  called  incoherence.  It  is  not 
every  maniac  who  is  really  incoherent ;  the  apparent 
incoherence  is  due  to  our  want  of  knowledge  of  the 
connecting  links  of  thought,  in  fact  of  our  ignor- 
ance of  the  method  of  thought-building  going  on 
in  the  patient's  mind.  As  in  dreams  the  most  ex- 
traordinary jumble  of  ideas  may  appear  before  us 
without  impressing  us  with  the  slightest  sense  of 
incongruity,  so  with  the  person  suffering  from  mania 
there  may  be  a  similar  condition.  To  the  patient 
himself  there  is  generally  a  pretty  definite  inter- 
pretation of  what  passes  in  his  mind,  and  generally, 
I  think,  the  incoherence  is  to  be  looked  upon  as  evi- 
dence of  rapid  change  of  idea  rather  than  a  succession 


Chap,  v.]  Incoherence.  109 

of  perfectly  isolated  and  disconnected  thoughts.  Just 
as  the  traveller,  resting  above  the  clouds  on  a  moun- 
tain top,  sees  peak  beyond  peak  reaching  above  the 
impenetrable  sea  of  cloud ;  the  peaks  alone  are 
visible,  yet  he  knows  that  deep  down  below  the  ob- 
scuring cloud  lie  the  foundations  of  the  mountains 
whose  summits  alone  are  visible,  so  we  remember  in 
our  dreams  but  a  few  of  the  things  that  have  passed 
through  our  minds,  the  connecting  ideas  having 
vanished.     A  similar  state  exists  in  mania. 

What  connection  would  one  see  between  Sir  James 
Simpson  and  a  second  Saviour,  till  gradually  one  finds 
the  idea  was  thus  evolved  ?  As  Christ  came  into  the 
world  to  pay  the  debt  of  sin,  but  did  not  abolish  the 
penalty  of  suffering,  and  as  now  Simpson  and  the  dis- 
covery of  chloroform  have  practically  annulled  suffer- 
ing, some  one  must  bear  the  weight  of  the  penalty. 

One  of  the  chief  characteristics  of  incoherence  and 
of  dream-thought  is  that  both  are  stimulated  by  sense- 
impressions  without  any  intermediate  thought-action. 
They  are  thought-reflexes,  if  I  may  use  the  term.  Just 
as,  when  asleep,  the  slightest  exposure  of  a  limb  to  cold, 
by  a  shifting  of  the  bed-clothing,  may  start  a  whole 
series  of  thoughts  about  skating,  the  Alps,  or  an 
Arctic  expedition,  to  be  suddenly  changed  into  the  fall 
from  a  precipice  suggested  by  some  slight  change  in 
the  position,  so,  in  the  insane,  a  sense-impression  sud- 
denly turns  aside  the  flow  of  thought  into  another  and 
unexpected  channel. 

Incoherence  of  the  tyj)e  just  described  is  a  chief 
feature  in  mania.  Fixed  delusive  conceptions  and 
ideas  that  have  been  called  monomanias  do  not  belong 
to  this  condition.  It  may  be  considered  that  the  feel- 
ing of  contentment,  of  well-being,  of  power  and  wealth, 
which  the  patient  suffering  from  mania  often  possesses, 
belongs  to  the  imaginative  side.  It  is,  however,  hard 
to  understand  how  the  fever  of   thought  should  be 


no         Insanity  AND  Allied  Neuroses.    [Chap.  v. 

associated  with  a  feeling  of  satisfaction ;  but  it  is  a 
constant  experience  to  find  acute  cases  perfectly  satis- 
fied with  their  mental  condition.  I  have  scarcely,  if 
ever,  met  a  person  suffering  from  mania  who  in  the 
least  appreciated  his  state.  This  feeling  of  satisfaction 
may  give  rise  to  the  nearest  approach  to  fixed  delu- 
sions. Thus,  a  young  fellow  who,  without  having 
any  opportunities  for  enjoying  life,  as  it  is  called, 
but  who  has  long  looked  upon  the  stage  as  a  haven  of 
license  and  a  pleasure  to  be  ardently  desired,  when 
he  becomes  maniacal  imagines  he  is  the  most  gifted  of 
actors ;  and  it  is  not  uncommon  for  us  to  receive  such 
cases  into  the  hospital  after  they  have  caused  annoy- 
ance at  one  theatre  or  another  by  the  persistence  of 
their  endeavours  to  obtain  engagements.  This  feeling 
of  personal  worth  may  become  the  one  most  prominent 
delusion,  and  may  really  be  a  serious  drawback  to 
recovery.  The  feeling  of  power  may  be  associated 
with  one  of  changed  personality,  the  patients  ima- 
gining they  are  royal  or  heroic.  And  here  the 
strange  association  of  ideas  again  works,  so  that  a 
Reginald  thinks  himself  born  to  be  a  king,  and  a 
John  Charles  considers  himself  to  be  a  successor  of 
the  Stuarts. 

As  far  as  judgment  is  concerned,  it  is  difficult  to 
say  that  maniacal  patients  are  without  power  of 
i  jndgina:;  but  one  of  the  most  characteristic  symptoms 
of  such  cases  is  the  inability  to  weigh  justly  their  sur- 
roundings and  their  companions.  It  is,  therefore, 
common  for  us  to  have  two  patients  at  a  time,  who 
agree  in  nothing  but  the  belief  that  every  patient  in 
the  asylum  is  there  unjustly;  or  that  those  who  are 
acting  peculiarly  are  doing  so  with  a  purpose,  desir- 
ing, in  fact,  to  remain  in  the  asylum  for  their  own 
objects ;  or  else  they  see  absolutely  nothing  singular 
in  the  strangest  and  wildest  excitement  in  others. 
Their  judgment  upon  other  things  may   be  correct ; 


Chap,  v.]  Judgment  and  Will.  iit 

they  may  be  able  to  play  chess,  or  discuss  politics. 
One  patient  in  Bethlem,  who  was  as  dangerous  as  a 
man  could  be,  and  full  of  insane  ideas,  was  able  to 
play  his  rubber,  fence,  or  chat  reasonably. 

The  will,  being  the  balance  of  motive,  is  uncertain, 
and  not  to  be  calculated  upon,  the  only  thing  marked 
about  it  being  its  changeableness.  The  person  with 
acute  mania,  unless  haunted  by  some  more  persistent 
hallucinations  than  usual,  is  as  changeable  in  his  will 
as  he  is  incoherent  in  his  speech.  Mania  is  a  condi- 
tion of  Aveakness,  as  I  have  said,  bodily,  and  the  man 
is  below  par;  so,  mentally,  his  faculties  are  unstable  and 
not  to  be  depended  upon.  There  is  no  steady  purpose, 
but  instability  with  emotional  display  :  like  the  child 
and  the  old  man,  he  is  ready  for  laughter  or  for  tears. 
Passion  of  all  kinds  is  easily  stimulated,  but  satisfac- 
tion rarely  follows.  As  one  might  expect,  the  weak 
man  is  irritable,  nervous,  and  cowardly ;  and,  with 
all  the  threats  which  are  heard  in  an  asylum,  it  is  rare 
for  the  acute  maniac  to  engage  in  an  open  attack  upon 
his  fellows. 

So  far,  then,  we  have  passed  in  review  the  symp- 
toms, bodily  and  mental,  which  are  grouped  together 
in  the  class  "  mania." 

Probably  no  one  case  exhibits  all  these  symptoms, 
but  all  are  directly  connected  with  a  condition  of 
nervous  instability. 

I  shall  now  describe  the  more  common  varieties 
which  occur  in  this  group. 

Pirst,  simple  acute  mania  may  be  divided  according 
to  whether  the  symptoms  most  affect  the  intellectual 
or  the  moral  (I  had  almost  said  organic)  side  of  the 
patient.  I  shall  consider  cases  of  the  latter  variety 
first,  because  they  are  so  near  in  many  respects  to  or- 
dinary cases  of  eccentricity.  The  cases  such  as  those 
now  under  review  are  probably  the  cause  of  more 
family  worry  and  distress  than  any  others ;  and  the 


T 1 2         Insanity  and  Allied  Neuroses.    [Chap.  v. 

reason  is  that  the  friends  cannot  recognise  the  slighter 
symptoms  of  insanity.  It  is  common  for  me  to  hear 
the  friends  of  such  patients  say,  "  1  believe  it  is  bad- 
ness in  my  relation,  and  I  have  done  everything  in 
my  power  to  knock  it  out  of  him/'  The  one  charac- 
teristic of  the  disorder  is  complete  moral  perversion. 
This,  however,  does  not  necessarily  imply  open  acts  of 
licentioiis  immorality  ;  but  it  connotes  change  in  dis- 
position, habits,  and  manner  of  thought  quite  out  of 
relationship  to  the  education  and  surroundings  of  the 
patient.  In  one  case  the  patient  always  showed 
evidence  of  an  approaching  attack  of  insanity  by 
changing  his  religious  creed,  and  by  seeking  some  new 
spiritual  guide.  Later  he  threw  off  all  religious  ideas, 
and  gave  himself  up  to  sensual  indulgence.  In  another 
case,  a  man  who  for  nearly  half  a  century  had  held  an 
important  position  in  a  public  office,  who  had  been 
a  bright  and  shining  light  of  English  middle-class 
society,  and  a  representative  of  respectable  dissent, 
took  to  visiting  public-house  bars,  making  love  to 
barmaids,  and  indulging  in  cocktails  and  cigars  in 
way  which  scandalised  his  religious  friends.  One 
was  bound  to  admit  that  this  man,  whose  memory  re- 
mained perfectly  good,  whose  judgment  upon  his  own 
professional  subjects  was  unimpaired,  and  who  was 
not  unreasonable  or  unreasoning,  was  nevertheless 
temporarily  changed,  and  that  the  change  was  the 
L-esult  of  brain  disease  of  some  sort,  which,  having 
passed  away,  left  him  as  well  as  ever,  and  regretful  of 
the  short  period  of  loss  of  self-control.  He  at  no 
time  during  the  attack  became  what  is  ordinarily 
called  maniacal. 

Such  cases  occur  among  women  as  well  as  men, 
and  it  is  common  for  us  to  have  one  or  two  examples 
in  Bethlem.  Take,  for  instance,  a  woman  a  little  past 
middle  life,  who  becomes  fidgety,  over-meddlesome, 
^nd  generous ;  she  is  anxious  to  make  garments  for 


Chap,  v.]     Intellectual  Acute  Mania.  113 

all  the  poor  children  of  the  metropolis.  Her  lodgings 
become  a  receptacle  for  a  motley  collection  of  what 
would  ordinarily  be  considered  by  hei'  to  be  rubbish. 
Now  she  prizes  the  heap  of  gaudy  rags,  and  is  full 
of  the  schemes  by  which  she  is  to  make  clothes  for 
some,  and  make  money  for  others  by  means  of  a  bazaar. 
In  the  asylum  she  begins  to  collect  everything, 
rags,  paper,  bones,  pins,  bits  of  glass,  soup-tins,  in 
fact  anything  that  can  be  found.  This  period  of  col- 
lecting is  associated  with  a  coquettish  manner, 
distinct  ideas  of  her  good  looks,  and  the  possibility 
of  her  getting  a  husband.  There  is  irritability,  and 
there  are  complaints  almost  daily  against  one  atten- 
dant or  another.  She  does  not  sleep  well,  and  has 
more  ailments  than  the  hypochondriac.  Her  state  of 
disturbance  having  lasted  for  several  months,  she 
vslowly  becomes  herself  again,  resumes  her  quiet 
orderly  life,  and  ceases  to  have  any  special  mission 
among  the  poor.  The  most  troublesome  of  such  cases, 
undoubtedly,  are  those  who  periodically  take  to  drink, 
the  danger  being  that  the  drink  may  tend  further  to 
establish  mental  unsoundness ;  for  most  cases  of 
insanity  of  this  kind  are  recurrent,  and  I  am  inclined 
to  think  that  many  of  them  have  strong  nervous  inhe- 
ritance, that,  in  fact,  they  might  by  some  writers  be 
looked  upon  as  cases  of  hereditary  insanity  exhibiting 
the  moral  perversion  common  in  this  group. 

I  have  to  consider  next  the  cases  of  acute  mania 
in  which  the  intellectual  faculties  are  chiefly  affected. 
This,  in  fact,  is  "  acute  mania  "  as  ordinarily  under- 
stood. There  is  nothing  special  in  the  causation 
of  this  disorder.  Anything  that  has  already  been 
considered  as  predisposing  and  exciting  causes  may 
act  in  the  production  of  this  form  of  insanity.  As 
remarked  in  discussing  the  last  subject,  maniacal 
conditions  are  those  of  physical  restlessness,  and 
the  symptoms  have  already  been  described  in  the 
1—14 


114       Insanity  and  Allied  Neuroses.     [Chap.  v. 

general  introduction  to  this  chapter.  Acute  mania 
occurs  mostly  at  the  periods  of  adult  and  mature  life. 
It  may,  however,  take  place  at  either  extreme,  so  that 
I  have  seen  cases  of  children,  one,  in  fact,  only  four 
years  old,  who  was  suffering  from  an  attack  of  acute 
mania,  as  evidenced  by  restlessness,  sleeplessness,  ex- 
citement, objectless  destructiveness,  great  irritability, 
and  vicious  propensities,  associated  also  with  perver- 
sions of  sense  and  de2)raved  appetite.  I  have  been 
consulted  about  one  case  on  the  verge  of  ninety,  who 
was  maniacal  then  for  the  first  time  in  his  life.  So  at 
the  other  extreme  of  life  one  may  meet  with  acute 
mania,  either  primary,  if  I  may  so  use  the  term,  that 
is,  coming  on  without  any  previous  well-marked  signs 
of  mental  degradation,  or  it  may  occur  as  the  conse- 
quence of  brain-wasting,  or  alteration  of  some  kind  in 
the  nutrition  of  the  nervous  centres,  Nearly  always 
acute  mania  is  preceded  by  a  period  of  mental  depres- 
sion and  sleeplessness.  These  symptoms  are  associated 
with  epigastric  uneasiness ;  the  patient  for  some  days 
or  weeks  feels  unable  to  fulfil  his  ordinary  duties, 
he  complains  of  lassitude,  and  his  friends  think  he  is 
becoming  hypochondriacal.  He  frequently  takes  to 
drugging  himself  with  narcotics,  tonics,  or  purgatives. 
This  period,  as  I  have  said,  may  be  of  very  variable 
length,  so  that  in  one  patient  it  is  short  and  of  slight 
intensity,  and  in  another  the  entire  stage  may  be  mis- 
taken for  one  of  profound  melancholia,  till  a  sudden 
outburst  of  mania  follows,  and  shows  the  melancholia 
to  have  been  but  the  initial  process  of  a  maniacal 
attack. 

It  is  not  necessary  here  to  point  out  all  the 
varieties  of  uneasy  melancholic  and  hypochondriacal 
feelings  which  may  precede  an  attack  of  mania.  The 
patient  often  takes  to  drink  at  this  period.  The 
excitement  may  develop  itself  slowly,  or  may  burst 
out  quite  suddenly,  a  very  slight  cause  of  excitement 


Chap,  v.]  Acute  Mania.  115 

determining  the  explosion.  With  this  there  is,  as  a 
rule,  no  increase  of  tempera.ture,  and^  except  during 
the  acts  of  violence,  there  is  no  increase  in  the  rate  of 
the  pulse  or  respiration ;  the  face  loses  colour  and 
becomes  sallow  and  anxious-looking.  There  is  often 
loss  of  appetite  and  constipation ;  the  tongue  may  be 
moist  and  tremulous  ;  and  here  it  may  be  noticed  that 
tongue-tremor  is  not  characteristic  of  general  paralysis, 
for,  in  my  experience,  more  tremulousness  is  met  with 
in  early  acute  mania  than  even  in  early  general 
paralysis.  The  attack  of  mania  may  be  a  continuous 
one,  the  symptoms  varying  slightly  from  day  to  day, 
the  thoughts  following  rapidly,  apparently  uncon- 
nectedly,  but  connected,  as  we  have  already  seen,  with 
impressions  from  without.  Violence  towards  others 
may  be  present,  but  generally  the  maniacal  patient  is 
not  the  one  who  is  to  be  dreaded,  as  he  is  more  like  a 
passionate  child  than  a  dangerous  being.  He  may  be 
stirred  to  violence  with  his  tongue,  and  impulsively 
destroy  property  ;  but  in  my  experience  he  is  rather 
cowardly  than  otherwise.  The  destructiveness  is 
most  marked  in  reference  to  his  clothes,  bedding,  and 
things  connected  with  his  meals.  Attacks  on  others 
may  be  made  by  persons  suffering  from  acute  mania 
in  consequence  of  false  ideas.  He  may  believe 
that,  being  of  great  importance  in  the  world,  his 
detention  in  an  asylum  is  withholding  him  from  the 
pleasures  and  duties  of  his  position  ;  or  he  may  be 
affected  by  hallucinations,  so  that  he  may  be  convinced 
that  it  is  his  duty  to  injure  this  person  or  the  other 
whom  he  believes  to  be  a  criminal  or  an  evil  spirit. 
The  safeguard,  however,  is  that  these  patients  are 
us^^ally  unable  to  combine  in  any  way,  and  they  give 
sufficient  warning  as  to  what  they  propose  doing.  An 
attack  of  acute  insanity  of  this  kind  may  continue  for 
weeks  and  months  together,  and  no  treatment  will  be 
found  to  have  any  good  effect   in  cutting  short  the 


ii6      Insanity  and  Allied  Neuroses.     [Chap.  v. 

attack.  About  five  years  ago  a  young  Greek  girl  was 
admitted  into  Bethlem,  who,  after  having  had  an 
attack  of  mental  depression,  was  suffering  from  the 
most  violent  acute  mania  it  is  possible  to  conceive.  In 
her  case,  which  I  may  take  as  an  example,  every 
variety  of  treatment  was  followed  without  any  good 
results,  but  in  the  end  she  again  passed  into  a  con- 
dition of  mental  depression,  and  then  recovered 
mentally,  to  die  some  years  afterwards  of  phthisis. 
She  was  a  girl  of  good  general  education,  of  strikingly 
handsome  appearance,  who  rapidly  passed  from  plump- 
ness into  a  condition  of  extreme  meagreness.  She 
seemed  to  be  able  to  do  without  rest  by  day  or  night ; 
she  chattered  and  sang ;  she  destroyed  all  her 
clothes  and  everything  breakable  that  came  in  her 
way,  and  she  had  to  be  clad  specially  in  a  kind  of 
combined  garment  because  she  was  constantly  in 
the  habit  of  standing  on  her  head  in  doing  what  is 
called  the  "  Catherine  wheel "  of  the  streets.  She  was 
treated  with  narcotics  of  every  description,  morphia, 
opium,  belladonna,  conium,  chloral,  camphor,  bromide 
of  potassium  ;  counter-irritation  was  tried,  the  wet 
pack  and  the  dry  pack,  seclusion,  abundance  of  stimu- 
lants, chloroform  for  hours  daily,  and  yet  the  dis- 
ordered process  seemed  in  no  way  to  be  hindered. 
This  serves  as  a  good  example  of  what  has  become  the 
creed  of  the  older  asylum  attendants,  that  an  acute 
attack  of  mania  is  a  process  which  has  to  be  passed 
through,  and  that  the  best  thing  to  be  done  is  to  guide 
and  not  interfere  with  it.  In  this  case  the  change 
was  a  steady  one.  I  would  say  that  the  more  pro- 
longed the  initial  melancholic  stage  the  longer  is  the 
second  stage  of  excitement  likely  to  be,  and  the  longer 
these  two  the  less  hopeful  the  prognosis,  and  the? 
greater  the  amount  of  excitement  the  greater  is  the 
tendency  for  the  patient  to  pass  into  a  condition  of 
mental  depression  afterwards.     This  depression  may 


Chap,  v.]  Recovery.  117 

be  of  two  kinds,  simple  exhaustion  of  the  nervous 
centres,  as  seen  in  partial  weak-mindedness,  or  de- 
pression of  the  melancholic  type. 

Other  cases  exhibit  a  peculiar  rhythmic  process 
in  recovery.  Patients  have  attacks  of  violence,  suc- 
ceeded by  periods  of  health  or  depression,  succeeded 
again  by  j)eriods  of  excitement,  followed  by  others  of 
depression.  This  process  may  last  for  a  considerable 
time,  and  then  the  attacks  of  mental  disorder  may 
become  shoj^ter  and  shorter,  till  at  last  a  condition  of 
health  is  regained.  These  cases  I  compare  to  the  swing 
of  a  pendulum,  and  I  have  shown  how  the  swing  of 
the  pendulum  through  an  arc  of  excitement  is  fol- 
lowed by  a  swing  through  an  arc  of  depression  ;  and 
as  the  stability  increased,  the  movement  was  through 
shorter  arcs  of  disturbance,  till  at  last  stability  was- 
re-established. 

Besides  the  above  ways,  cure  may  be  sudden, 
and  this  unexpected  cure  may  be  accidental  or 
natural.  Thus,  every  year  one  has  cases  of  insane 
patients  who  have  recovered  their  mental  balance  as 
the  result  of  a  physical  illness.  One  patient  gets  an 
attack  of  erysipelas  and  his  mind  clears  ;  another  gets 
an  attack  of  neuralgia,  or  has  a  gum-boil,  causing 
swollen  face  and  much  pain,  and  he  recovers.  Similar 
bodily  disorders  may  produce  similar  results  in  the 
melancholic  as  well  as  in  the  maniacal.  Certain 
cases  get  well  only  to  relapse,  and  one  of  the  most 
important  questions  is  not  merely  the  prognosis  of  the 
immediate  attack,  but  the  prognosis  as  to  recurrence. 
Simple  acute  mania  is  a  disorder  which  is  very  likely 
to  recur  if  it  make  its  appearance  in  a  family  known 
to  be  neurotic.  The  prognosis,  too,  is  worse  after 
each  recurrence,  and  it  is  also  made  more  grave  when 
slight  phyisical  or  moral  disturbances,  such  as  are 
certain  to  recur,  can  be  shown  to  be  the  causes.  Thus, 
a  patient  whose  attacks  were  started  by  child-birth 


ii8       Insanity  AND  Allied  N'euroses.      [Chap.v. 

or  other  physiological  process,  is  likely  to  have  recur- 
rences ;  and,  as  I  have  said,  each  recurrence  makes 
the  prognosis  worse.  For  although  it  does  not  follow 
that  a  patient  who  has  had  six  or  eight  attacks  should 
not  recover  from  any  more,  yet  the  chances  are  that 
she  will  to  the  end  of  her  life  be  subject  to  recur- 
rences upon  the  slightest  provocation,  and  that  her 
children  (if  she  have  any)  will  be  of  the  most  unstable 
nervous  type.  Thus,  in  the  case  of  a  woman  who, 
herself  being  of  nervous  family,  had  two  children, 
and  with  each  child  an  attack  of  insanity,  one  be- 
came a  lunatic  and  was  subject  to  recurrent  attacks 
of  acute  mania,  till  she  became  permanently  altered 
in  her  mental  life,  and  will  remain  for  the  rest  of 
her  days  an  eccentric  emotional  person,  liable  to 
outbreaks  of  acute  violence,  while  the  other  was  a  suf- 
ferer from  every  variety  of  hysterical  trouble. 

It  is  noteworthy  that  persons  with  strong  nervous 
inheritance  sometimes  pass  through  a  series  of  nerve 
storms  with  comparatively  little  damage  to  their  intel- 
lects, while  others,  less  nervous,  suffer  much  more 
severely  from  single  attacks.  Thus,  one  patient  in 
Bethlem,  who  was  subject  for  years  to  recurrences 
of  most  violent  acute  mania,  maintained  in  the  in- 
tervals an  extraordinary  amount  of  mental  vigour. 
She  belonged  to  a  family  in  which  nervous  disease 
was  common. 

A  large  number  of  cases  of  acute  mania  recover 
from  their  first  attacks,  and  I  would  further  say 
that  cures  may  be  perfect,  so  that  the  patient 
becomes  as  sane  and  reasonable  as  ever  he  was  in 
his  life.  The  result,  however,  of  mania  may  be  less 
satisfactory.  A  patient,  after  having  had  an  acute 
attack  of  mania,  may  first  be  morally  damaged,  so  that 
he  takes  to  evil  ways  j  and  I  fear  that  the  friends  of 
patients  occasionally  attribute  such  moral  perversion 
to  the  associations  and  companionships  of  an  asylum. 


Chap,  v.]  Moral  Ferj'ersion.  119 

Young  cases  suffer  specially  in  this  way.  I  say  that 
I  would  prefer  not  admitting  lads  into  Bethlem, 
because  however  careful  one  may  be,  such  patients 
are  specially  apt  to  learn  evil  from  their  elders,  and 
the  cases  to  which  I  am  now  referring  are  more  parti- 
cularly liable  to  this  contamination.  They  have  lost 
a  great  deal  of  mental  vigour  ;  the  acute  attack  has 
weakened  their  judgment  and  impaired  their  intellect, 
allowing  their  lower  animal  side  to  have  more  power 
than  is  good.  Such  cases,  then,  after  an  attack  of 
acute  mania,  especially  when  they  have  been  treated 
in  a  general  asylum,  may,  though  discharged  re- 
covered, be  looked  upon  as  going  with  a  moral  limp 
After  discharge  they  frequently  decline  to  follow 
their  old  vocation,  and  become  a  burden  to  their 
friends.  This  is  not  all,  for  they  often  give  way 
to  drink  and  to  other  excesses,  and  not  uncommonly 
pass  into  the  criminal  classes. 

Besides  this  moral  perversion  which  may  follow 
an  attack  of  mania,  some  intellectual  peculiarity  may 
bo  the  scar  which  is  left,  and  the  patient,  quitting 
the  asylum  recovered  from  his  acute  attack,  has 
now  some  habit  which  for  the  rest  of  his  life  stamps 
him  as  an  eccentric.  He  may  be  solitary,  penurious, 
given  to  odd  ways  of  dressing  and  of  living ;  he  may 
be  in  the  habit  of  talking  to  himself,  or  he  may 
have  some  one  special  delusion,  which  he  keeps  out 
of  sight  of  the  ordinary  friend,  but  which  neverthe- 
less influences  the  rest  of  his  life. 

When  later  writing  about  the  so-called  cases  of 
monomania,  I  shall  point  out  that  most  of  these 
have  passed  through  mental  storms,  and  that  the  ex- 
traordinary delusions  are  but  the  result  of  these  acute 
attacks.  Acute  mania  may  be  succeeded  by  any  one 
of  the  many  varieties  of  weak-mindedness,  so  that  the 
stage  of  dementia  which  is  common  after  the  acute 
attack   may  persist  and  leave  the  patient  in   a  state 


I20      Insanity  AND  Allied  Neuroses.      [Chap.  v. 

of  second  childhood  \  or  it  may  leave  him  fairly 
well-behaved  and  fairly  active,  but  his  whole  in- 
tellectual being  has  been  reduced  to  a  lower  level,  so 
that  the  man  who  was  a  leading  barrister  may  now 
be  contented  with  a  supply  of  drawing  materials, 
with  which  he  passes  his  time  in  making  hideous 
copies  from  the  illustrated  papers.  Another  man, 
who  at  one  time  was  an  officer  in  the  army,  is  now 
content  to  polish  pebbles  against  the  wall,  in  the 
hope  thereby  of  getting  a  cigar  or  a  little  tobacco 
from  a  visitor  in  return  for  his  gems,  while  others 
become  hewers  of  wood  and  drawers  of  water  to  an 
asylum.  At  present  we  have  in  Bethlem  an  old  bank 
clerk  who  cleans  the  floors  and  fetches  the  meals, 
having  no  longer  any  wish  to  return  to  his  former  oc- 
cupation. 

Another  more  troublesome  result  of  acute  mania 
may  be  that  the  patient  passes  into  a  state  of  chronic 
noisy  incoherence,  chattering  the  whole  day  long, 
generally  in  an  aggrieved  way  or  with  threatening  and 
abusive  language.  Every  asylum  has  cases  of  this 
kind,  in  which  there  is  a  special  sort  of  logorrhoea, 
the  association  of  ideas  being  often  utterly  untraceable, 
and .  no  condition  of  brain  yet  being  known  to 
correspond  with  this  condition  of  chronic  mania. 

Under  the  head  of  acute  delirious  mania  we  saw 
that  death  was  not  an  uncommon  sequel  to  that  dis- 
order, but  in  simple  acute  mania  it  is  not  nearly  so 
common  to  meet  with  fatal  results.  We  see  acute 
mania  ending  fatally  when  associated  with  some  other 
bodily  disease  or  injury,  and  from  time  to  time  we 
meet  with  cases  who  die  from  the  excitement  of 
mania.  Such  cases  have  gone  on  talking,  raving,  and 
destroying  day  and  night ;  they  may  have  taken  food 
freely,  but  they  have  steadily  lost  ground  and  at  length 
have  died. 

The  prognosis  in  all  cases  of  acute  mania,   then, 


Chap,  v.]  Acute  Mania.  121 

must  be  guarded,  and  I  would  say  tliat,  with  any 
case  of  acute  mania,  in  which  excitement  was  great, 
sleeplessness  well  marked,  food  either  not  taken  at  all, 
or  not  assimilated,  must  be  regarded  with  danger, 
especially  in  young  and  old  cases.  I  have  seen  several 
cases  of  elderly  women  dying  comparatively  sud- 
denly ;  they  have  been  excited  for  weeks  after  the 
attack  of  mania ;  then  becoming  unexpectedly  quiet, 
they  have  sunk  and  died. 

Acute  mania  recovering  hy  degrees  and  with  remis- 
sions.— Reginald  IST.,  single,  22,  admitted  October, 
student,  first  attack  of  insanity,  no  nervous  inheri- 
tance ;  the  causes  of  this  outbreak  were  over-study, 
and  disappointment  with  change  in  his  prospects. 

The  first  symptoms  were  restless  irritability,  a 
ravenous  appetite,  and  false  ideas  as  to  his  father's 
wealth  and  position.  He  was  loquacious,  believed 
he  would  be  a  hero,  and  that  he  could  write  as  well  as 
Shelley.  He  became  extravagant  and  witty.  There 
was  more  brilliancy  than  one  ordinarily  sees  in  mania. 
He  asked  me  for  a  definition  of  acute  mania,  and 
answered  it  himself  by  saying,  "  it  is  believing  your- 
self to  be  a  boxing  man,  and  proving  it  to  demon- 
stration ;  "  he  also  referred  to  the  analysis  of  emotions 
as  a  filthy  process.  Within  a  few  days  of  his  admis- 
sion he  became  quiet,  tidy,  and  well-behaved  ;  but  this 
lasted  only  a  week,  after  which  he  became  as  noisy  as 
ever ;  by  November  3rd  he  was  removed  to  a  con- 
valescent gallery,  only  to  be  sent  in  ten  days  to  the 
refractory  ward  again.  For  the  next  few  weeks  he 
varied  ;  for  a  few  days  being  quiet,  and  then  again 
breaking  out  with  all  his  old  violence.  In  one  attack 
his  violence  was  extreme,  and  hyoscyamine  was  tried 
in  vain.  After  this  he  slowly  recovered,  and  was  dis- 
charged. 

Acute  mania,  rapid  recovery. — Elizabeth  W.,  mar- 
ried, age  34,  three  children,  youngest  19  months  old. 


122      Insanity  and  Allied  Neuroses.      [Chap.  v. 

No  insane  inheritance.  Has  suffered  from  rheumatic 
fever ;  was  said  to  have  had  incipient  phthisis.  The 
cause  of  her  present  state  was  said  to  be  pecuniary 
trouble  and  domestic  anxiety.  Her  husband  was 
intemperate,  and  frightened  her  while  he  was  suf- 
fering from  delirium  tremens.  She  was  admitted 
into  Bethlem  on  January  23  ;  her  first  symptoms  were 
violent  emotional  disturbance,  which  began  four  days 
before  admission.  She  became  restless,  and  refused 
food.  She  was  incoherent  in  speech  and  in  ideas, 
and  her  movements  were  wild  and  uncontrolled.  She 
was  sleepless ;  she  said  she  was  Jesus  Christ  at  one 
moment,  and  that  she  was  dead  the  next. 

On  admission  she  was  extremely  thin  and  anaemic  ; 
she  talked  in  a  rambling  way,  her  eyes  were  bright, 
pupils  large,  hair  rough  and  semi-erect;  she  gesticulated 
and  moved  her  fingers  and  hands  in  a  rhythmic  way. 
She  made  rhymes;  she  passed  her  urine  and  faeces 
under  her.     Pulse  120,  temperature  100*4°. 

The  temperature  soon  fell  to  99°,  though  there 
was  very  little  change  in  any  other  symptom  for 
some  days.     She  refused  all  food. 

By  January  30  she  was  reported  as  more  quiet,  and 
as  taking  her  food,  but  still  very  weak. 

February  4th. — She  said  that  yesterday  she 
suddenly  awoke  to  herself,  and  wondered  where  she 
was,  and  why ;  she  said  she  had  lost  recollection  of 
much  of  the  past  few  weeks. 

February  15.  —  Still  weak,  but  progressing 
favourably.  After  being  tried  with  change  of  air 
and  leave  of  absence,  she  was  discharged  well  on 
March  26th. 

Mania  Diay  he  'part  of  the  insane  process,  and  not 
the  whole.  Thus,  in  folie  circulaire,  mania  is  succeeded 
by  melancholia,  to  be  again  succeeded  either  by  a 
period  of  health,  or  by  a  fresh  attack  of  mania. 
There  is  nothing  special  in  the  attack  of  mania,  it 


Chap,  v.]  '^  FOLIE    ClRCULAIRF.y  1 23 

being  characterised  by  the  usual  bodily  and  mental 
disturbances  which  we  have  already  described.  The 
j)eriods  of  excitement  are  not  of  absolutely  equal 
length,  and  the  relationships  between  the  periods  of 
depression  and  those  of  excitement  vary.  This  form 
of  mental  disorder  is  extremely  rare,  in  my  experience, 
in  England.  I  am  used  to  cases  of  mania  and  melan- 
cholia  recurring  at  irregular  intervals,  in  which  the 
end  is  mental  destruction  ;  but  the  establishment  of  a 
regular  process  of  recurrent  periods,  such  as  described, 
is  practically  unknown  to  me,  the  cases  which  I  have 
met  with  falling  more  properly  into  either  cases  of 
recurrent  mania,  or  cases  of  mania  ending  in  per- 
manent weak-mindedness. 

Folie  circulaire,  as  described,  is  a  mental  disorder 
most  frequently  met  with  in  women,  coming  on  often 
soon  after  puberty,  rarely  cured,  in  which  a  period  of 
excitement  is  followed  by  a  period  of  rest  and  of 
melancholy,  the  three  stages  following  each  other  in 
any  order,  there  being  probably  the  most  with  de- 
pression first,  which  is  followed  by  mania,  which  is  suc- 
ceeded by  a  period  of  health,  or  at  least  by  a  period  of 
comparative  health.  Patients  suffering  from  this  dis- 
order are  said  rarely  to  be  quite  themselves  even  at 
their  best.  I  have  seen  many  cases  in  which  there 
have  been  cycles  of  this  kind,  but  the  periods  of 
depression  or  of  weak-mindedness  became  longer  and 
longer,  while  the  stages  of  health  were  restricted  till 
in  the  end  mental  weakness  resulted. 

In  some  women  the  menstrual  period  always  starts 
a  fresh  outbreak  of  excitement ;  but  such  cases  are  re- 
current, and  do  not  properly  belong  to  the  group 
called  Jblie  circulaire. 

Mania  may  be  the  first  or  one  of  the  earlier  symp- 
toms of  general  paralysis  of  the  insane.  In  some 
cases  the  mania  appears  suddenly  ;  but  I  consider, 
as  a  rule,  that  in  such  cases  the  way  has  been  paved 


124      Insanity  and  Allied  Neuroses.      [Chap.  v. 

for  the  outbreak  of  excitement  by  antecedent  de- 
generation, and  that  in  this  respect  they  resemble 
others  to  which  I  have  referred  as  cases  of  acute  ex- 
citement following  chronic  brain  change.  The  acnte 
mania  of  general  paralysis  may  be  preceded  by  the 
ordinary  melancholic  period  often  assuming  a 
markedly  hypochondriacal  type.  The  attack  of 
mania  may  be  of  short  duration,  and  leave  the 
patient  profoundly  altered,  as  far  as  his  mental 
abilities  are  concerned,  but  yet  with  little  appear- 
ance of  physical  illness.  Attacks  of  mania  may 
appear  from  time  to  time  in  the  progress  of  general 
paralysis,  each  attack  tending  rapidly  to  mental  de- 
struction. There  are  no  special  characteristics  to 
enable  one  at  once  to  diagnose  the  mania  of  general 
paralysis  from  that  due  to  other  causes.  The  dia- 
gnosis must  be  made  from  the  physical  conditions  and 
symptoms. 

Mania  may  be  associated  with  epilepsy,  it  may 
precede  the  epilepsy,  or  take  the  place  of  a  fit ; 
but  more  commonly  the  patient,  after  a  fit  of 
convulsions  with  unconsciousness,  becomes  quite 
suddenly  violent.  Such  cases  are  among  the  most 
dangerous  possible,  as  the  outbreaks  of  destructive 
violence  come  on  as  suddenly  as  do  the  fits  them- 
selves. Thus,  some  years  ago  I  saw  the  wife  of 
a  publican  who  was  said  to  have  had  an  attack  of 
apoplexy  some  little  time  before.  There  was  no 
doubt  she  had  been  strange  in  habits  and  manner, 
and  that  she  had  lost  consciousness  at  times  ;  these 
losses  of  consciousness  were,  however,  looked  upon  as 
simple  fainting  fits,  but  when  she  had  a  very  severe 
attack  of  convulsions,  affecting  one  side,  it  was  supposed 
she  was  suffering  from  a  fit  of  apoplexy,  but  to  the 
astonishment  of  her  friends  and  the  doctor,  she 
suddenly  recovered  consciousness  after  sleep,  and 
became  violent  and  destructive.     When  first  called  I 


Chap,  v.]  Mania   with  Epilepsy.  125 

found  her  unconscious  and  breathing  stertorously, 
with  clonic  convulsions  of  the  left  side,  and  with  only 
the  history  given  me  by  friends  that  she  had  an 
attack  of  paralysis.  On  the  first  occasion  I  had 
been  misled  into  the  idea  that  this  kind  of  attack 
was  an  apopletic  seizure,  and  prescribed  accordingly. 
Next  day  I  was  suddenly  summoned  to  find  lier 
in  the  wildest  state  of  excitement,  rushing  about 
her  house,  breaking  the  ornaments,  and  abusing  her 
servants  and  relations.  This  period  of  excitement 
lasted  nearly  two  days,  after  which  she  was  again 
herself.  On  another  occasion,  somewhat  later,  she 
had  a  similar  fit ;  but  having  learnt  by  experience  the 
nature  of  the  seizure,  I  prescribed  a  full  dose  of 
chloral  hydrate  whilst  she  was  still  unconscious,  the 
result  being  that  she  slept  continuously  for  about 
twenty-four  hours,  and  when  she  awoke  she  was  free 
from  mania.  When  succeeding  attacks  took  place 
she  was  sometimes  tried  with  chloral,  and  sometimes 
without,  but  always  became  maniacal  if  the  drup; 
were  withheld.  Cases  of  this  kind  are  common 
enough  in  the  larger  county  asylums.  There  are  cases 
in  which  a  large  amount  of  purposive  action  may  take 
place,  and  serious  injury  may  be  done,  and  yet  the 
patient  may  be  without  the  faintest  recollection  of 
what  has  taken  place  during  the  period  of  violence. 
That  crime  has  been  committed  by  patients  during  a 
state  of  epileptic  furor  I  have  no  doubt,  crimes,  too, 
of  a  most  brutal  and  devilish  kind.  The  perpetrator  of 
some  brutal  murder  may  apparently  have  taken  care 
to  secure  his  victim,  and  to  hide  his  crime,  but  yet 
there  is  a  complete  ignorance  of  all  that  has  hap- 
pened. He  may  impress  the  jury  unfavourably 
by  this  apparent  indifference,  and  by  his  denial  of 
any  knowledge  of  what  took  place,  although  it  is 
clearly  proved  that  he  appeared  to  see  and  avoid 
witnesses.     But  one  of  the  most  striking  things  about 


126       Insanity  and  Allied  Neuroses.     [Chap.  v. 

epilepsy  is  the  complete  break  of  continuity  of 
thought,  which  so  generally  occurs  both  in  the  graver 
and  in  the  slighter  attacks  of  epilepsy. 

In  a  later  chapter  the  relations  of  epilepsy  to 
insanity  will  be  fully  considered,  but  before  leaving 
the  subject  I  will  repeat  that  the  mania  following 
epilepsy  may  be  of  the  most  violent,  destructive, 
impulsive  character  which  can  be  conceived,  and  that, 
unlike  ordinary  mania,  it  leaves  not  even  a  perverted 
memory  behind. 

As  one  of  the  greatest  difficulties  lies  in  dis- 
tinguishino;  between  acute  mania  and  acute  delirium, 
I  must  call  attention  to  the  fact  that  delirium  may 
pass  into  mania ;  this  occurs  most  frequently  in 
persons  with  direct  insane  inheritance. 

Thus  I  have  seen  attacks  of  acute  mania  follow 
the  delirium  of  fevers,  acute  alcoholism,  and  the 
delirium  resulting  from  belladonna,  and  from  the 
administration  of  chloroform. 

Acute  mania  may  take  the  place  of  hysteria  or  of 
spasmodic  asthma,  and  I  shall  not  be  surprised  to 
meet  with  other  conditions,  such  as  angina  and  hypo- 
chondriasis, which  may  prove  to  be  equivalents  of  a 
maniacal  pain  storm. 

The  patSi©log>"  of  aiaaBiia.— Any  condition  of 
physical  illness  may  set  up  an  attack  of  mania  in 
predisposed  persons.  Mania  must  be  looked  upon 
as  depending  rather  upon  weakness  than  inflam- 
mation. The  excitement  and  restlessness  are  results 
of  want  of  conti-ol,  not  of  excess  of  power.  The 
circulation  is  feeble,  and  the  power  of  re-action  small. 
Power  of  assimilation  is  also  generally  impaired,  the 
secretions  and  excretions  not  being  normal.  The 
pallor  of  the  face  points  to  the  anaemia,  and  the  wide 
pupil  to  the  nervous  weakness.  As  far  as  the  local 
pathology  is  concerned,  but  little  that  is  definite  can 
be  said. 


Chap,  v.]         The  Pathology  of  Mania.  127 

Doubtless  there  are  local  or  general  changes  in  the 
nervous  system,  but  no  clue  has  yet  been  obtained  to 
any  special  change  which  can  be  called  the  physical 
cause  of  maniacal  symptoms,  nor  have  we  sufficient 
data  to  point  to  as  evidence  of  the  changes  produced 
by  mania  in  the  brain  or  other  nervous  organs. 

Such  being  the  case,  all  that  can  be  done  is  either 
to  describe  what  one  would  expect  to  find  (and  this 
in  the  human  body  is  very  misleading  and  untrust- 
worthy), or  else,  by  recording  stray  but  scattered 
facts,  leave  to  later  observers  the  arranging  and  com- 
paring of  results. 

I  shall,  for  my  part,  give  a  few  of  these  detached 
observations  under  this  head.  After  death  from 
acute  mania,  I  have  several  times  found  no  changes  in 
the  brain  which  were  visible  to  the  naked  eye.  I 
have  in  some  such  cases  found  local  disease  elsewhere, 
as  in  the  lungs,  ovaries,  kidneys,  heart,  or  liver. 

In  some  cases  I  have  found  evidences  of  old- 
standing  wasting  of  the  brain  which  seemed  to  have 
prepared  the  way  to  the  fatal  attack  of  acute  mania. 

I  have  found  the  brain  remarkably  blanched  on 
the  one  hand,  and  on  the  other  I  have  found  either 
venous  congestion,  or  fine  capillary  injection,  general 
or  local. 

Frequently  I  have  found  excess  of  subarachnoid 
fluid.  Ko  importance  attaches  to  the  milky  patches 
found  in  the  arachnoid,  and  there  is  no  special  condition 
of  dura  mater,  or  of  any  particular  convolutions. 

Histologically  I  have  rarely  failed  to  find,  in  fatal 
cases  of  acute  mania,  changes  in  the  nerve  cells,  more 
especially  in  the  pyramidal  layer.  The  nerve  pro- 
cesses may  be  wanting,  the  cells  may  be  swollen  and 
indefinite  in  outline,  and  in  some  cases  they  are  much 
Avasted  or  suffering  from  degeneration  of  one  form  or 
another.  In  some  cases  there  was  certainly  excess  of 
leucocytes  in  the  vessel  sheaths,  or  parallel  to  them. 


128       Insanity  and  Allied  Neuroses,    [Chap.  vi. 

There  is,  then,  no  special  change  to  be  seen  in  the 
brain,  and  in  the  sympathetic,  as  far  as  I  have 
examined  the  cervical  and  some  of  the  abdominal 
ganglia,  I  have  failed  to  discover  a  clue  to  the  dis- 
order. 

Before  concluding  this  section,  I  must  give  as  my 
experience,  that  persons  may  die  of  acute  mania,  and 
yet  their  bodies  may  exhibit  nothing  which  a  skilled 
pathologist  would,  at  present,  at  least,  be  able  to  say 
was  sufficient  to  destroy  life. 


CHAPTER   VI. 

HYPOCHONDRIASIS    AND    MELANCHOLIA. 

Hypochondriasis — Allied  to  hysteria  and  insanity — Simple  hy- 
pochondriasis— Insane  hypochondi'iasis — General  or  local 
hypochondriasis — Feeling  of  impending  death  or  of  a  general 
disease — Brain  hypochondriasis— Gastro -intestina],  throat, 
epigastric,  rectal  hypochondriasis  —  Reproductive  organ 
hypochondriasis — Hypochondriasis  mixed  with  melancholia. 

Hypochonclriasis.— Just  as,  in  considering  mania, 
I  pointed  out  that  hysteria  in  many  respects  might  be 
considered  an  undeveloped  mania,  and  might  be 
looked  upon  as  a  very  closely  related  condition,  one 
which  had  the  same  orign,  and  might  have  the  same 
termination,  so  in  this  chapter  I  shall  Legin  by  con- 
sidering the  condition  called  hypochondriasis,  and  its 
further  development  of  melancholia. 

We  begin  mental  life  by  receiving  impressions,  and 
slowly  building  up,  with  those  impressions,  a  power 
to  receive  higher  ones,  just  as  we  commence  motor 
life  by  combming  the  simple  muscular  forces  till  they 
become  the  wonderful  machine  that  speaks  and 
writes.  Step  after  step  is  gained  both  on  the  sensory 
and    motor   sides.       From  the  lower  we  rise   to  the 


Chap.  VI.]  Hypochondriasis.  129 

higher  ;  and  in  healthy  development,  forgetting  those 
things  which  are  behind,  we  stretch  forward  to  the 
new.  The  muscular  adaptations  are  organised,  so 
that  they  become  automatic,  and  a  similar  organisation 
takes  place  with  respect  to  our  sensations.  Doubtless, 
the  child  feels  much  more  real  satisfaction  in  his 
simple  meals  than  does  the  gourmet.  To  the  child, 
the  satisfaction  is  one  that  is  felt  by  his  whole  body. 
I  am  in  the  habit  of  saying  that,  in  my  belief,  the 
persistence  of  the  ego  does  not  lie  so  much  in  any 
highly  organised  nervous  centre,  but  has  its  origin 
with  the  earliest  processes  of  nutrition,  and  that  the 
ego  springs  into  being  rather  along  the  gastro- 
intestinal track  than,  Minerva-like,  from  the  brain. 
Self-feeling  is  altered  in  many  cases  by  a  change 
in  the  digestive  functions ;  and  just  as  we  have  the 
most  perfect  movement,  without  a  knowledge  of  the 
muscles  which  are  being  brought  into  action,  so  we 
can,  and  must,  really  have  only  perfect  sensation 
when  the  sense-organs  are  in  perfect  health,  and 
react  automatically  to  the  surroundings.  A  man 
who  is  in  health  receives  impressions  without  knowing 
it ;  when  he  has  to  strain  his  ears  or  eyes,  he  is  not 
acting  in  harmony  ;  when  he  is  thinking  he  should 
have  no  feeling  of  weight  or  pressure  within  his  skull, 
and  when  digesting,  he  should  have  no  knowledge  of 
the  existence  of  his  stomach. 

In  the  class  of  patients  whom  we  are  about  to 
consider,  the  functions  are  from  one  cause  or  another 
thrown  out  of  gear,  so  that  the  automatic  action  of 
sensation  no  longer  exists.  The  person  feels  every- 
thing he  does,  and  knows  from  his  sensations  that 
he  has  viscera.  The  knowledge  of  this  necessarily 
distracts  his  attention  from  what  might  be  called 
the  higher,  and  concentrates  them  upon  the  lower  or 
more  organic  sides  of  his  being.  Nearly  every  patient 
suffering  from  melancholia  complains  of  feelings  of 
j-14 


130       Insanity  AND  Allied  Neuroses.    [Chap.  vi. 

illness.  In  mania,  we  saw  the  feeling  was  one  of 
buoyancy  and  exuberance.  With  melancholia  we 
meet  with  a  slowing  of  all  vital  processes.  What  the 
pathological  basis  of  melancholia  may  be  one  cannot 
at  present  tell.  It  however  seems,  in  most  cases, 
that  it  must  be  associated  with  impaired  nutrition  of 
the  nervous  centres  and  the  conducting  system.  In- 
stead of  conduction  and  reaction  to  impressions  being 
active,  they  are  so  slow  that  they  can  be  felt  in  their 
action. 

Hypochondriasis  and  melancholia  depend  more 
probably  for  their  existence  upon  some  general  bodily 
condition  than  do  most  other  forms  of  insanity.  The 
person  of  unstable  nervous  system,  who  has  a  worry- 
ing or  constantly  painful  feeling,  due  to  some  bodily 
disease,  is  likely  to  be  absorbed  by  this  constant  irri- 
tation, and  have  his  life  centred,  as  it  were,  around 
the  seat  of  painful  impression.  As  we  shall  see,  some 
centres  seem  specially  liable  to  start  these  morbid 
feelings,  making  the  man,  in  one  case,  hypochon- 
driacal, and  in  another,  melancholic.  Before,  how- 
ever, proceeding  farther,  I  would  say  that  the  dis- 
tinction between  hypochondriasis  and  melancholia  is 
rather  arbitrary.  It  may  be  convenient,  but  it  is 
not  philosophical  to  treat  of  the  body  apart  from 
the  mind,  and  the  physical  symptoms  separately  fi-om 
the  mental.  Purther  consideration  will  show  that 
a  man  who  believes  himself  forsaken  by  God,  may, 
after  all,  have  got  that  idea  in  consequence  of  some 
gastro-intestinal  trouble,  and  that  damnation  has 
been  his  method  of  interpreting  dyspepsia.  It  has 
been  generally  said  that  morbid  sensations  are  the 
essential  of  hypochondriasis,  and  morbid  feelings 
the  essential  of  melancholia.  But,  as  I  have  said,  the 
distinction  is  one  that  is  scarcely  satisfactory,  and 
when  considering  cases  as  they  present  themselves 
in    practice,  we  shall  see  that  patients    may  belong 


Chap.  VI. 1  Hypochondriasis.  131 

to  a  hypochondriacal  class  on  the  one  hand,  and 
yet  have  distinctly  melancholic  symptoms  on  the 
other. 

For  convenience,  I  shall  only  consider  at  first  the 
cases  of  bodily  hypochondriasis,  for  they  will  form  a 
useful  group  by  which  to  connect  the  melancholia 
and  hypochondriasis  classes.  I  shall  have  to  describe 
cases  of  mental  sensitiveness  without  any  defined 
feeling  of  unworthiness,  cases  in  which  people,  instead 
of  looking  at  their  tongues  and  feeling  their  jDulses, 
are  constantly  asking  themselves  if  they  are  doing 
their  duty. 

Of  ordinary  hypochondriasis  there  are  three 
classes  seen  in  an  asylam,  besides  the  sufferers  from 
general  hypochondriasis,  who  complain  of  some 
general  disease  like  syphilis  or  hydrophobia,  or  who 
believe  themselves  to  be  on  the  point  of  death.  And 
just  as  the  hysterical  woman  may  remain  hysterical 
all  her  life  and  never  become  insane,  so  the  hypo- 
chondriacal patient  may  remain  hypochondriacal 
to  the  end.  The  classes  consist  first  of  those  who 
complain  of  brain-working  or  brain  loss ;  secondly, 
of  those  who  complain,  as  does  the  ordinary  hy]->o- 
chondriac,  of  some  digestive  trouble ;  and,  thirdly, 
those  who  believe  that  there  are  some  defects  in  their 
reproductive  organs.  Emotional  depression  springs 
from  a  feeling  of  real  bodily  illness,  but  the  illness  is 
rarely  of  what  may  be  called  a  coarse  kind,  but  is 
the  result  of  impaired  function,  and  not  of  structural 
disease.  In  insane  hypochondriasis  it  is  common  to 
find  a  very  clearly  marked  localisation  of  the  com- 
plaints, and  though  one  does  meet  hypochondriasis  of 
the  ordinary  type  in  an  asylum,  this  is  less  common ; 
it  is  not  of  these  that  I  now  write. 

Patients  recovering  from  an  attack  of  insanity 
frequently  feel  nervously  tender,  and  complain  daily 
of  some  fresh  ailment,  wanting  a  liniment  to-day  and 


132       Insanity  and  Allied  Neuroses.    [Chap.  vi. 

a  ionic  to-morrow.  Though  hypochondriasis  is  gene- 
rally seen  among  men  in  an  asylum,  it  is  also  seen 
among  women.  It  occurs  in  the  middle-aged  more 
than  in  the  J^oung  ;  but  we  frequently  meet  with  sexual 
hypochondriasis  among  the  latter.  Young  people 
also  exhibit  various  phases  of  brain  hypochondriasis, 
the  gastro-intestinal  cases  belonging  chiefly,  but  not 
solely,  to  those  of  more  mature  years.  The  causation 
may  be  general  or  local ;  there  may  be  some  physical 
cause  for  the  feeling,  and  the  concentration  of  atten- 
tion upon  the  weak  spot  may  have  exalted  its  sensitive- 
ness to  a  diseased  point.  Intellectually,  these  people 
rarely,  if  ever,  show  signs  of  weakness ;  at  all  events 
not  for  years,  and  I  believe  that  the  hypochondriacal 
patient  rarely  ends  in  dementia.  He  often  is  con- 
ceited j  and  it  seems  to  me  that  hypochondriasis  may 
be  looked  ujDon  as  a  kind  of  conceit.  Patient  after 
patient  will  say  that  he  suffers  as  no  one  ever  suffered 
before,  that  it  is  quite  useless  to  compare  him  with 
his  neighbours,  and  that  he  is  utterly  unlike  all  others. 
The  association  of  ideas  with  him  is  natural.  Will 
seems  generally  enfeebled  in  consequence  of  inability 
to  divert  his  thoughts  from  painful  sensations  ;  the 
appetite  is  bad,  constipation  generally  exists  causing 
him  further  anxiety,  and  he  is  often  irritable  and 
emotional.  His  memory  is  good,  and  his  judgment 
of  things,  apart  from  himself,  is  good,  so  that  he  could 
be  trusted  in  a  court  of  law  as  an  ordinary  witness. 
He  is  not  subject  to  hallucinations  of  his  senses,  his 
perversions  being  illusions ;  that  is,  he  misinterprets 
what  is  presented  to  his  senses.  Sleep  is  broken,  and 
often  disturbed  by  dreams  of  an  amorous  type,  which 
still  further  distress  him.  A  hypochondriac  may  kill 
himself  or  another,  but  generally  he  appears  to  be 
cowardly,  and  many  have  told  me  that,  although 
tired  of  life,  they  never  for  a  moment  dreamt  of 
killing  themselves. 


Chap.  VI.]  Brain  Hypochondriasis.  133 

Tlie  hypochondriacal  condition  is  not  a  very 
hopeful  one.  Prognosis  depends  upon  the  length  of 
time  in  which  it  has  been  developing,  the  age  of  the 
patient,  and  the  physical  basis  from  which  it  springs. 
The  older  the  case,  and  the  longer  and  the  more 
steadily  it  has  been  developing,  the  less  hope  is  there 
of  recovery.  In  some  it  takes  a  long  time  before  it 
becomes  really  an  insane  condition.  A  case  begins 
with  recurring  periods  of  depression,  in  which  the 
patient  feels  out  of  sorts,  and  commences  to  over- 
haul his  various  bodily  functions  and  habits ;  he 
wonders  whether  it  is  smoking  or  drinking  which  is 
causing  his  sleeplessness,  whether  tea  disagrees  with 
him,  or  if  milk  should  be  his  only  drink ;  he  exhibits 
irritability  and  inability  to  work.  He  tries  all  sorts 
of  nostrums  recommended  by  his  friends,  follows  the 
teetotallers  or  the  vegetarians,  being  in  turn  delighted 
with  the  results  of  his  experiment  and  disgusted 
with  their  failure.  Such  patients  stand  a  very  great 
chance  of  being  mismanaged,  for  between  the  attacks 
of  depression  they  appear  so  well  to  their  friends, 
and  express  such  a  powerful  conviction  that  they  will 
never  be  ill  again,  that  they  are  not  definitely  put 
under  treatment  till  the  morbid  feelings  have  become 
established.  The  insane  hypochondriac  does  not  live 
to  a  great  age,  as  a  rule,  the  older  man  or  woman 
wearing  out  and  dying  of  some  secondary  trouble, 
such  as  inflammation  of  the  lungs.  The  younger 
cases  ma}^  rarely  pass  into  weak-mindedness,  or  mind 
restriction  ;  or  if  sufficient  lever-power  to  induce  them 
to  work  can  be  brought  to  bear  upon  them,  they  may 
completely  recover. 

Oroup  I.— JSraiti  liypoclioiidriasis.— In  an 
asylum,  although  headache  is  not  very  commonly 
complained  of,  yet  Ave  constantly  hear  complaints 
about  uneasy  feelings  in  the  brain.  One  class  of 
patients,   both  ■  male  and  female,  complains  much  of 


T34       Insanity  and  Allied  Neuroses.     [Chap.vi. 

changes  in  the  brain.  In  these  cases  it  is  almost  in- 
variably found  that  there  has  been  some  sexual  trouble. 
I  have  met  with  many  complaints  about  strange 
sensations  at  the  top  of  the  head  and  in  the  brain  in 
patients  who  say  that  they  have  injured  themselves 
by  masturbation.  I  have  met  with  this  also  in  cases 
where  sexual  excess  has  been  indulged  in,  and  I  am 
inclined  to  think  it  may  occur  also  in  cases  where 
there  has  been  an  unnatural  suppression  of  all  sexual 
instincts.  The  patient  tells  you  that  he  is  sure  his 
brain  is  dried  up  or  changed  in  some  way,  and  one 
man  described  the  feeling  as  that  of  being  possessed 
of  a  brain  like  a  Spanish  onion,  in  which  the  thin 
scaly  coverings  had  been  removed  without  causing 
pain,  but  now  that  the  fleshy  layers  were  being 
removed  the  pain  was  dreadful.  In  this  case,  change 
of  surroundings,  active  and  energetic  companions, 
and  some  unpleasant  physical  trouble  acted  satis- 
factorily in  starting  him  along  a  fresh  line,  which 
has  so  far  been  followed  with  beneficial  results. 
Women  suffer  similarly,  and  in  them  the  pain  on  the 
top  of  the  head  is  constantly  associated  with  men- 
strual irregularity.  At  the  climacteric  I  have 
frequently  seen  similar  cases.  Thus,  in  a  patient 
recently  in  Bethlem,  the  feeling  complained  of  was 
that  of  opening  and  shutting  of  the  brain,  so  that  she 
would  ask  me  to  listen  to  the  top  of  her  head,  or  at 
least  to  place  my  hand  there  to  feel  the  snapping. 
If  such  condition  depend  upon  a  cause  like  the 
climacteric,  the  prognosis  is  better  than  when  it 
simply  depends  on  the  laborious  action  of  degenerat- 
ing organs.  The  following  case,  taken  down  from 
the  patient's  own  lips,  conveys  more  graphically  than 
any  other  description  could,  the  misery  of  the  brain 
hypochondriac. 

"  I  am  a  medical  man,  and  my  age  is  forty-seven. 
I  always  had  a  very  good  constitution,  and  possessed 


Chap. VI.]  Statement  of  a  Hypochondriac.       135 

great  muscular  strength,  active  habits,  and  an  ex- 
citable temperament.  One  morning  in  March,  1879, 
being  at  the  time  in  perfect  health,  I  was  tempted  to 
commit  self-abuse.  1  had  done  it  before,  but  not 
very  frequently,  having  foolishly  abstained  from  mar- 
riage, I  was  immediately  afterwards  seized  with 
giddiness.  Whilst  dressing  before  the  looking-glass 
I  noticed  that  my  face  was  flushed  in  a  manner  I  had 
never  before  seen,  being  livid  and  congested,  and  of  a 
dark  purple  hue.  My  pupils  were  also  exceedingly 
dilated  at  the  time.  On  that  day  I  felt  my  gait 
tottering  and  my  temper  disposed  to  be  irritable. 
That  night  1  had  very  little  sleep,  and  suffered  severe 
pain  in  my  head.  From  that  time  sleep  departed 
more  and  more.  I  resorted  successively  to  every 
known  narcotic  drug,  gradually  increasing  the  doses, 
until  I  gave  them  up  as  inert.  I  went  away  to  moun- 
tain scenes  to  try  change  and  exercise,  but  no  benefit 
accrued.  I  returned  and  made  a  desperate  struggle 
to  carry  on  my  practice,  but  finding  myself  becoming 
worse,  I  went  to  the  Hydropathic  Hospital  in  York- 
shire, and  underwent  the  treatment  there  without 
any  good  result.  I  then  transferred  myself  to  the 
Leeds  Infirmary,  and  was  under  Dr.  Cliftbrd  Allbutt. 
There  drugs  were  given  to  me,  but  nothing  produced 
sleep.  I  prayed  to  be  bled  or  leeched,  but  was 
refused.  I  then  bribed  the  nurse  to  put  fifteen 
leeches  on  my  temples,  after  which  I  obtained,  for 
the  first  time  for  many  months,  three  hours'  sleep.  I 
was  so  pleased  with  the  result  that  I  dressed  myself 
and  returned  home  to  my  practice  ;  but  finding  my- 
self getting  worse,  I  left  in  November,  1879,  and 
since  then  I  have  spent  two  years  mostly  in  bed, 
suffering  intense  pain  all  the  time ;  and  for  the 
last  two  years  I  have  been  a  patient  in  Bethlem.  My 
principal  troubles  now  are  almost  entire  sleeplessness, 
intense  pain  in  the  back  of  the  head,  most  severe  in 


136       Insanity  and  Allied  Neuroses.    [Chap.  vi. 

the  mornings  and  after  food,  especially  liquid  food.  I 
am  troubled  with  dreadful  libidinous  desires,  in  spite 
of  all  efforts  to  avoid  them.  This  was,  however, 
relieved  to  some  extent  by  bromide  of  potassium ^  in 
large  doses.  I  am  now  slowly  but  surely  getting 
weaker,  losing  flesh  ;  my  circulation  is  becoming  more 
feeble,  my  appetite  poor,  a  dragging  pain  at  the 
heart  sometimes,  but  not  often  ;  at  night  spasm  of  the 
larynx  nearly  chokes  me.  About  three  years  ago  I 
was  struck  by  a  remarkable  appearance  of  the  veins 
in  my  hands,  and  they  presented  the  appearance  of 
containing  little  or  no  blood,  but  on  opening  a  vein 
for  nearly  an  inch  in  length,  I  could  squeeze  only 
a  slight  drop  of  blood  from  it ;  whereas,  on  the  con- 
trary, the  deeper  veins  were  unnaturally  distended. 
When  the  paroxysms  of  feverish  excitement  are  on  me 
my  whole  body'  feels  as  if  the  blood  were  nearly 
boiling.  I  have  often  wished  the  medical  men  in 
Bethlem  to  test  the  supposed  delusion  as  to  the  state 
of  my  veins,  but  they  have  not  done  so.  I  notice 
but  little  diminution  in  my  mental  activity,  and  this 
convinces  me  that  no  structural  change  of  brain 
structure  has  taken  place,  and  that  the  true  nature  of 
the  lesion  is  paralysis  of  the  vaso-motor  system,  more 
or  less  of  the  whole  body,  but  more  especially  of  the 
sinuses  in  the  posterior  part  of  the  brain,  as  I  dis- 
tinctly feel  intense  pressure,  and  on  moving  my  head 
creaking  noises  are  heard.  I  attribute  these  noises 
to  the  stretching  of  bands  of  lymph  thrown  out 
around  the  sinuses,  so  that  they  may  be  kept  dilated. 
I  am  perfectly  convinced  that  recovery  is  impossible, 
that  all  treatment  is  useless,  and  that  this  is,  with- 
out doubt,  the  true  meaning  of  the  passage  in  1  John 
V.  16  :  "  There  is  a  sin  unto  death  :  not  concerning  this 
do  I  say  that  he  should  make  request "  (Revised  ver- 
sion). And  I  believe  this  evidence  is  overwhelming,  for 
I  was  in  magnificent  health  before  doing  this  sin,  and 


Chap.  VI.]        Gastric  Hypochondriasis.  137 

was  struck  down  instantaneously,  and  have  been  in 
misery  and  pain  ever  since.  My  bowels  are  con- 
stipated occasionally^  but  at  rare  intervals.  I  have 
pseudo-tetanic  spasms  down  the  spinal  cord,  and  at 
times  intense  dragging,  gnawing  pain  in  the  same 
region. " 

Another  male  patient  recently  in  Bethlem  was 
fully  convinced  that  all  his  back-brain  had  been 
removed  by  a  miraculous  interposition  of  Providence, 
and  that  he  possessed  nothing  but  his  face  and,  as  he 
said,  a  little  span  of  brain  which  enabled  him  to 
recognise  his  friends.  From  time  to  time,  from  week 
to  week,  the  poor  fellow  would  march  about  with  his 
hand  on  the  top  of  his  head,  begging  us  to  have  com- 
passion on  him  and  communicate  with  his  relations  in 
order  to  take  him  home  and  die.  The  misery  of  his 
existence  seemed  to  be  complete,  and  the  prognosis, 
though  wholly  unfavourable  as  to  cure,  did  not  even 
give  the  hope  of  annihilation  of  the  suffering,  which  so 
frequently  occurs  to  the  ordinary  melancholic  patient 
when  he  becomes  weak-minded.  The  misery  in  his 
case  would  not  become  mechanical,  but  would  slowly 
wear  him  to  the  grave. 

Oroup  2.— Gastric  liypochondriasis.— In 
this  group  we  have  three  divisions.  First,  patients 
who  complain  of  obstruction  or  disease  about  the 
throat;  secondly,  those  who  complain  of  similar  feel- 
ings and  uneasiness  at  the  pit  of  the  stomach ;  and 
thirdly,  those  whose  complaints  are  referred  to  the 
lower  bowel.  There  are  other  cases  in  which  two  or 
more  of  these  symptoms  are  united,  and  one  meets 
constantly  with  cases  in  which  reference  is  made  to 
uneasy  feelings,  referred  to  one  or  other  part  of  the 
digestive  track.  A  patient  at  present  in  Bethlem 
thinks  that  his  food  passes  directly  into  his  left 
arm,  whereas  another  imagines  that  it  passes  into 
his  circulation.       Of  the  cases  with   throat  trouble. 


138       Insanity  and  Allied  Neuroses.    [Chap.  vi. 

examples  occur  both  among  the  men  and  the  women. 
I  have  met  with  cases  of  simple  exaggerations  of 
hysterical  globus  in  young  patients,  and  I  have  met 
also  with  similar  cases  in  men  at  the  extreme  of  life. 
One    young    man   was   constantly    in    the    hands    of 


A  case  of  Hypochondriasis,  with,  ideas  of  Bowel  Obstr action. 


quacks  (who,  by  the  way,  probably  live  more  on 
hypochondriacs  than  on  any  other  class),  in  con- 
sequence of  an  idea  that  his  throat  was  contracted, 
and  that  it  was  impossible  for  him  to  swallow. 
He  came  of  a  nervous  and  phthisical  stock.  He 
had  been  nurtured  among  an  emotionally  religious 
sect,  and  at  the  onset  of  manhood  be  became  ner- 
vously and  hypochondriacally  disordered.      Change  of 


ciiap.  VI.]        Gastric  Hypochondriasis.  139 

surroundings,    absence   of  quacks,  use  of  tonics,   and 
sea-air  did  him  good. 

In  another  case,  where  the  father  was  an  inmate 
of  Bethlem,  the  son  Avas  admitted  suffering  from 
hypochondriacal  insanity,  with  the  persistent  idea  that 


A  case  of  Hyjpocliondriacal  Melancholia. 

there  was  some  malignant  growth  at  the  back  of  his 
throat.  He  took  hours  to  swallow  any  food  if  left  to 
himself,  and  would  become  violent  and  excited  if 
contradicted.  Everything  was  done  to  convince  him 
that  no  obstruction  existed.  Probangs  were  passed, 
his  throat  examined  by  the  laryngoscope,  he  was 
allowed  to  examine  his  own  throat  by  reflected 
light,  and,  as  a  last  resort,   he  was  sent  to  a  leading 


140       Insanity  and  Allied  Neuroses.   [Chap.  vi. 

laryngologist  who  certified  that  his  throat  was  normal. 
Keason,  however,  is  wasted  on  the  insane  hypochon- 
driac, and  this  patient,  after  more  than  a  year  of 
treatment,  was  discharged  uncured,  but  in  robust 
general  health.  I  have  frequently  seen  him  since, 
and  his  condition  is  unaltered,  no  sense  of  duty  to 
relations  or  friends  being  able  to  stimulate  him  to 
work,  and  no  reason  can  convince  him  but  that  he 
is  slowly  dying  of  general  wasting.  And  when  it 
is  pointed  out  to  him  that  he  is  getting  fat,  he  says 
it  is  but  the  infiltration  of  his  tissues  with  diseased 
matter. 

There  is  one  other  case  worthy  of  note  under  this 
head.  It  is  that  of  a  patient  who  returns  to  Bethlem 
every  few  years  wdth  exactly  similar  ideas.  He  is 
admitted  in  a  depressed  and  anxious  state,  refusing  to 
speak  at  first,  but  pointing  to  his  throat,  which  he 
wishes  us  to  understand  is  closed  up.  In  a  day  or 
two  he  will  say  that  he  has  no  doubt  about  it,  for 
although  in  other  attacks  he  felt  in  the  same  way  and 
thought  there  was  throat  obstruction,  now  he  is 
completely  convinced  that  his  end  has  come.  He 
invariably  loses  all  these  ideas  in  a  few  weeks,  and 
goes  out  well. 

The  above  cases  are  good  examples  of  throat 
hypochondriasis,  as  seen  in  young  hysterical  or 
nervous  patients,  in  the  adult  with  strong  nervous 
inheritance,  and  in  the  old  associated  with  periodic 
attacks  of  mental  depression  connected  with  physical 
weakness. 

In  the  next  group  the  troubles  are  referred  to  the 
epigastrium.  This  is  the  ordinary  seat  of  painful 
impressions  in  all  nervous  disorders.  And  the 
Psalmist,  in  saying  that  his  "  bowels  yearn,"  recog- 
nised the  fact  that  emotional  feeling  and  disturbance 
were  ever  associated  with  an  uneasy  sensation  in  the 
abdomen.     In  early  melancholia,  in  acute  mania,  even 


Chap.  VI.  i     HVPOCHONDRIACAL    Mf.LANCHOLY.  I4T 

ill  simple  fits  of  passion,  uneasy  epigastric  sensation 
is  experienced.  In  acute  mania  this  may  lead  to 
excess  of  stimulants  taken  with  a  view  of  soothing 
the  uncomfortable  feeling,  Avhereas  in  the  melancholic 
patient  the  sensation  may  give  rise  to  some  fixed 
delusion.  Patients  both  old  and  young,  male  and 
female,  suffer  in  this  way,  and  describe  in  different 
ways  their  uneasy  feelings.  One  will  say  that  he 
feels  the  food  passing  down  the  gullet  and  then 
drop  into  a  cloacal  cavity,  and  another  will  allege 
that  it  passes  from  the  gullet  into  some  tissue  of  his 
body,  or  into  the  main  circulatory  system.  In  all 
these  cases  the  bodily  symptoms  differ  in  no  way  from 
those  of  the  ordinary  hypochondriac.  '  The  insane 
person  is  but  an  exaggeration  of  the  ordinary 
hypochondriac,  and  the  prognosis  depends  entirely 
on  general  conditions.  In  some  of  these  cases  the 
chief  difficulty  in  getting  them  to  take  sufficient  food 
is,  that  they  are  convinced  that  there  is  a  limit  to  the 
capacity  of  their  abdomens,  and  they  will  refuse  with 
violence  to  take  more  food,  and  may  have  to  be  fed 
artificially. 

One  practical  point  is  noteworthy,  and  it  is  that 
most  of  these  patients  have  concave  abdomens,  and 
although  they  may  waste,  and,  in  many  respects,  have 
much  the  appearance  of  patients  suffering  from  severe 
chronic  or  malignant  disease,  yet,  with  all  their  com- 
plaints, no  local  obstruction,  nor  any  dilatation  of 
the  gut  will  be  found.  Dr.  Ord,  of  St.  Thomas's 
Hospital_,  thinks  that  in  some  such  cases  there  is 
to  be  detected,  even  in  life,  contraction  of  the  sigmoid 
flexure,  and  that  the  stool  passed  in  such  cases  will 
be  found  to  be  extremely  small  and  pipe-like, 

Hyiiocliondriacal  melancholy  with  ideas  of  bowel 
obstruction  and  unv^orthiness,  in  a  young  woman. — 
Kate  M.,  single,  twenty-nine.  Maternal  aunt  in- 
sane ;  mother  and  two  aunts  died  of  phthisis.      This 


142       Insanity  and  Allied  Neuroses.   [Chnp.  vi. 

patient  spat  blood  twelve  months  ago  and  lost  flesh. 
Menstruation  at  times  profuse.  This  is  the  first 
attack  of  insanity,  and  it  began  with  a  sudden  out- 
break of  destructive  violence,  which  in  a  few  hours 
passed  into  melancholy.  On  admission  she  was 
wasted  and  sorrowful -looking,  silent  and  unoccu- 
pied. She  refused  food,  and  said  she  was  a  great 
sinner.  She  had  to  be  fed  with  the  stomach  pump 
for  some  v/eeks.  She  was  sleepless,  and  would  stand 
about  all  night,  and  for  this  I  had  her  placed  in  "  dry 
pack." 

After  two  months'  feeding  by  stomach  tube,  or  by 
nose-tube,  some  salt  was  added  to  the  beef-tea,  and  a 
thirst  was  created,  which  she  herself  satisfied. 

Prom  this  time  she  took  some  food,  and  said  she 
was  much  better.  She  was  sent  to  our  convalescent 
home,  where  she  spent  most  of  the  year  1883.  She 
gained  flesh,  but  still  maintained  that  she  had  a 
disease  which  prevented  her  eating.  She  said  that  all 
her  life  she  had  been  constipated,  but  that  now^  her 
bowels  were  completely  closed,  so  that  nothing  ever 
could  pass  again. 

She  was  tried  on  leave  of  absence  at  home,  but  at 
the  end  of  three  weeks  was  brought  back  much 
wasted.  Probably  the  patient  will  die  of  phthisis  in 
a  year. 

In  some  of  these  cases  ulceration  of  the  duodenum 
has  been  proved  to  exist,  by  Dr.  Claye  Shaw,  and  I 
have  found  similar  pathological  changes.  Patients 
belonging  to  this  group,  as  a  rule,  slowly  lose  flesh 
and  strength,  become  bed-ridden,  and  die.  It  is  well 
that  every  method  of  feeding  should  be  pursued,  and 
that  the  food  should  be  varied  in  every  way,  in  the 
hope  of  finding  some  which  will  be  retained  and 
assimilated.  The  many  patent  foods,  such  as  the 
peptones  and  extract  of  meat,  with  pepsine  or  other 
digestives,  may  be  administered.     Nutrient  enemata 


Chap. VI.]  Gastric  Hypochondriasis.  743 

may  be  given,  altliougli  I  have  rarely  seen  good  fol- 
low their  use,  when  the  other  methods  have  failed, 
and  I  have  once  or  twice  seen  symptoms  of  collapse 
in  such  cases  follow  rectal  feeding. 

The  last  variety  of  this  group  contains  cases  in 
which  the  complaint  is  that  the  bowels  never  act, 
and  that  from  some  cause  or  another  the  lower 
bowel  is  closed.  There  is  no  distinction  in  general 
appearances  between  this  class  and  the  last,  the 
symptoms  being  similar  in  almost  every  particular. 
Recently  we  had  a  patient  in  Bethlem,  who  for 
over  a  year  was  possessed  by  the  idea  that  all  his 
food  was  retained  and  gradually  passed  under  his 
skin,  so  that,  as  he  said,  he  had  tons  of  potatoes  in 
him ;  and  although  when  weighed  from  month  to 
month  he  was  shown  to  be  steadily  losing  weight, 
this  did  not  satisfy  him,  for  he  reiterated,  as  a  fact, 
the  statement  that  he  had  tons  of  food  about  him. 
He  steadily  lost  strength,  g.nd  died,  there  being  no 
physical  cause  for  the  trouble  in  his  abdomen  to 
account  for  his  painful  sensations. 

A  similar  case  is  that  of  a  woman,  single, 
fifty-two  years  of  age,  who  had  a  previous  attack 
of  insanity,  from  which  she  recovered.  She  was 
admitted  into  Bethlem  in  the  spring  of  1883,  pos- 
sessed with  the  ideas  that  she  was  eternally  lost, 
that  her  blood  was  turned  into  water,  and  that  her 
bowels  were  filling  up.  She  was  constantly  trying 
to  force  a  passage  with  her  fingers  (and  this  is 
one  of  the  most  trying  symptoms  which  occur  in 
these  patients,  the  constant  endeavour  to  relieve  in 
some  way  the  uneasy  sensations  from  which  they  are 
suffering).  For  a  time  this  patient  lost  flesh  and 
strength,  but  after  seven  months'  treatment  she  began 
to  get  stout.  She  was  still,  however,  possessed  with 
'  the  same  miserable  feelings  and  unhappy  sensations. 
I  fear  the   case  will  pass  into  a  chronic  state  from 


144      Lysanitv  and  Allied  N'euroses.    [Chap.  vi. 

wliicli  she  will  never  recover.  This  last  case  serves 
as  a  good  example  of  the  whole  class. 

It  is  comparatively  rare  to  meet  in  an  asylum  a 
patient  whose  complaint  about  visceral  sensations 
is  not  joined  to  some  idea  of  moral  un worthiness ; 
and  it  will  be  almost  invariably  found  that  the 
patient  who  thinks  he  has  lost  his  inside,  or  that 
nothing  passes  through  him,  will  sooner  or  later  be 
convinced  that  his  soul  is  wrong  in  one  way  or 
another. 

Each  case  of  hypochondriasis  requires  special 
treatment.  The  young  case  requires  exercise,  liberal 
diet,  and  if  possible  change  of  scene,  change  of  com- 
panions, and  such  conditions  as  are  best  obtained 
by  foreign  travel  with  skilled  attendant  or  medical 
companion.  A  doctor's  house  in  the  country,  Avhere 
the  patient  is  taken  about  pretty  regularly  by  the 
medical  man,  is  also  of  use,  but  I  believe  many  cases 
are  spoilt  for  want  of  early  and  decided  cutting  off 
from  old  religious  and  social  surroundings.  Tonics, 
in  the  form  of  iron,  arsenic^  or  zinc,  are  useful,  but 
no  good  will  be  done  to  such  a  patient  unless  he  be 
allowed  to  take  some  simple  form  of  aperient  pretty 
regularly.  I  am  in  the  habit  of  commencing  with 
some  mineral  water  every  morning  before  break- 
fast, or  giving  tamar  Indien,  or  encouraging  the 
habit  of  taking  fruit  stewed  or  fresh,  or  oatmeal 
porridge.  Too  much  attention  must  not  be  paid 
to  the  state  of  the  bowels,  but  yet  there  is  consti- 
pation in  nearly  all  the  cases,  and  it  is  just  as  well 
to  recognise  the  fact.  If  purgatives  or  aperients  of 
the  kind  described  fail,  it  is  well  to  try  belladonna 
alone  or  with  nux  vomica,  and  I  have  found  good 
i-esults  in  the  administration  of  five  grains  of  the 
extract  of  aloes  and  one  grain  of  quinine  daily.  To 
place  the  patient  under  the  best  hygienic  conditions 
as  to   food,    stimulants,   and  surroundings   should  be 


Chap.  VI.]         Sexual  Hvpochondriasis,  145 

the  chief  object  ;  then  if  the  patient  be  young,  and 
has  not  suffered  long  from  the  disease,  he  may  recover. 

Oroiip  3.— Sexual.  — Though  ordinary  hypo- 
chondriasis occurs  mostly  in  elderly  men,  there  is  a 
variety  of  the  same  disorder  commonly  met  with  in 
young  and  middle-aged  men  and  women.  Nothing  in 
this  world  so  depresses  a  man  as  the  belief  that  he 
is  impotent,  and  whether  he  has  been  in  the  habit  of 
using  his  reproductive  organs  or  not,  the  idea  that 
he  is  unmanned  reduces  him  to  despair ;  and  although 
I  have  said  that  as  a  rule  the  hypochondriac  is  not 
actively  suicidal,  I  have  here  to  qualify  that  state- 
ment in  reference  to  the  cases  suffering  from  sexual' 
hypochondriasis. 

Besides  the  cases  of  middle-aged  men  who  believe 
themselves  to  be  impotent,  there  are  other  cases  of 
youths  who  have  given  way  to  masturbation.  Such 
youths  pass  into  a  state  of  self  analysis,  and  of  study 
and  contemplation  of  their  reproductive  organs  and 
their  functions  in  the  same  way  that  the  ordinary 
hypochondriac  studies  his  digestion. 

In  some  cases  the  idea  is  that  there  is  something 
or  other  wrong,  and  no  reasoning  or  explanation  is 
able  to  persuade  them  to  the  contrary.  Either  the  pa- 
tient is  haunted  with  an  idea  that  he  is  physically  and 
morally  ruined  because  he  has  erections  of  the  penis, 
or  he  is  equally  distracted  because  they  are  absent. 
This  class  is  the  one  which  gradually  develops  ideas 
about  spermatorrhoea.  Take,  for  example,  a  man, 
twenty-eight  years  old,  who  was  from  early  boyhood 
given  to  self-abuse.  He  married  with  the  idea  that 
he  would  thus,  at  all  events,  get  rid  of  that  vice,  and 
j)ass  into  a  healthier  and  more  physiological  condition. 
For  a  time  he  seemed  better,  but  he  indulged  in  the 
most  extreme  way  in  sexual  gratification.  He  con- 
tinued at  his  work,  but  became  nervous  because 
the  sexual  act  became  less  pleasurable,  and  he 
K— 14 


146      Insanity  and  Allied  Neuroses.    [Chap.  vi. 

was  gradually  convinced  that  lie  was  suiTering  from 
spermatorrhcEa.  His  whole  ideas  were  concentrated 
upon  this  matter.  He  consulted  doctors,  quacks,  profes- 
sional medical  works,  and  followed  every  particular 
advice  which  he  could  get,  at  one  time  exhausting 
himself  by  abstinence  from  meat  and  stimulants, 
and  at  another  time  overdrawing  his  physical  ac- 
count by  long  and  weakening  exercise.  Notwith- 
standing all  his  endeavours,  the  so-called  sperma- 
torrhoea became  worse  and  worse,  so  that,  as  he  ex- 
pressed it,  the  mere  going  to  the  closet,  or  brushing  by 
a  woman  in  the  street,  would  produce  an  emission 
without  any  sensation.  Do  what  he  would,  the  idea 
followed  him  into  the  workshop,  the  church,  and  the 
street  that  he  was  slowly  being  drained  away.  I 
found  that  arsenic  and  avoidance  of  doctors  did  him 
more  good  than  anything  else.  I  impressed  on  him, 
at  the  same  time,  the  importance  of  continuing  at  his 
work,  and  trying  to  occupy  his  mind  in  one  way  or 
another. 

Case  of  sexual  hypochondriasis ;  recovery, 
— A  coachman,  who  had  been  a  trusted  servant  of 
one  of  our  English  noblemen,  and  who  had  led  the 
rather  free  life  of  a  gentleman's  gentleman  during 
the  seasons  in  London,  had  not  only  contracted  some- 
what extravagant  habits,  but  also  had  managed  to  get 
venereal  disease  in  its  various  forms.  He  became 
engaged  to  be  married,  and  then  a  reformation  took 
place  in  his  conduct ;  but  he  was  surprised  to  find  that 
this  purer  form  of  affection  was  less  associated  with 
erotic  feeling  than  he  expected,  and  he  became  pos- 
sessed by  the  idea  that  he  was  impotent.  His  one 
idea  was  that  it  was  of  no  use  his  living,  that  he  was 
no  longer  fit  to  be  reckoned  among  men  ;  and  although, 
if  roused  from  these  ideas,  he  would  talk  not  only  in- 
telligently, but  pleasantly,  about  his  past  experiences, 
he  soon  relapsed  when  left  to  himself.     After  twelve 


Chap. vi.i  Sexual  Hypochondriasis,  147 

months'  treatment  at  another  asylum  he  was  brought 
to  Bethlem,  and  having  been  over  a  year  there  I 
tried  the  effect  of  forcing  him  back  into  his  old  asso- 
ciations, and  daily  a  former  job-master  to  his  master 
came  to  take  him  out  for  drives  in  the  park  and 
elsewhere.  For  some  weeks  little  progress  was  made, 
yet,  undoubtedly,  his  interest  was  returning  to  his  old 
pursuits,  and  before  three  months  had  passed  he  was 
sufficiently  well  to  be  sent  on  leave  of  absence  j  at 
the  end  of  his  leave  he  was  discharged  recovered,  and 
has  not  only  lost  his  ideas  about  impotence,  but  has 
been  satisfactorily  married  to  his  former  love,  and  is 
in  full  work. 

It  is  comparatively  rare  to  meet  with  women 
suffering  from  similar  ideas ;  and  I  am  in  doubt 
whether  to  place  the  following  case  under  this  head,  or 
rather  to  look  upon  it  as  the  outcome  of  ordinary  me- 
lancholia. A  young  woman,  who,  by  the  way,  was 
begotten  by  a  father  while  he  was  himself  on  leave  of 
absence  from  an  asylum,  having  become  engaged  to  be 
married  to  a  young  man  suitable  in  every  way,  took  a 
vague  fancy  that  it  was  wrong  to  marry.  She  treated 
her  lover  with  indifference,  and  caused  him  consider- 
able worry  and  annoyance  ;  but  he  fancied  these  were 
the  ways  of  women,  and  were  tests  of  his  affection,  and 
submitted  to  all  her  freaks,  the  more  especially  as  her 
mother  said,  "  it  will  be  all  right  when  once  married." 
After  several  contretemps  the  wedding-day  arrived,  and 
the  young  couple  were  married  ;  it  turned  out  after- 
wards that  the  bride  had  to  be  freely  stimulated  with 
brandy  before  she  could  be  got  to  church.  There  was 
some  trouble  about  changing  her  dress,  and  getting 
her  into  her  travelling  costume  ;  but  this  was  accom- 
plished, and  bride  and  bridegroom  started  for  their 
future  home,  where  they  were  to  spend  their  honey- 
moon. It  was  with  difficulty  that  the  bride  was  per- 
suaded to  go  to  bed,  and  on  the  bridegroom  repairing 


148       Insanity  and  Allied  Neuroses.    [Chap.  vi. 

to  the  bridal  chamber  he  found  his  bride  still  in  her 
clothes,  lying  outside  the  bed.  No  persuasion  could 
induce  her  to  undress,  and  the  matter-of-fact  bride- 
groom went  to  bed,  and  slept  without  his  bride.  The 
bride  spent  the  night  in  restlessly  moaning  and  picking 
her  fingers,  saying  she  was  unnatural,  and  not  like 
other  women.  It  was  proved  conclusively  that  there 
was  no  physical  incapacity  on  the  part  of  the  bride  or 
bridegroom,  and  the  case  having  been  tried  in  the 
divorce  court,  nullity  of  marriage  was  decreed. 

In  this  last  case  everything  depended  rather  upon 
the  ordinary  melancholic  feelings  that  something  was 
wrong  being  referred  to  the  reproductive  organs,  and 
so,  though  not  a  perfectly  pure  case  of  hypochondriasis, 
sufficiently  resembles  it  to  be  cited  here.  And  there 
are  many  young  women  admitted  into  Bethlem  with 
vague  feelings  of  being  unnatural  in  consequence  of 
suppression  of  the  menses ;  these  generally  recover  in 
mind  and  body  under  tonic  and  general  treatment, 
with  the  re-establishment  of  the  function. 

A  group  of  strange  cases  closely  connected  with 
the  above  is  represented  by  some  instances  in  which 
some  act  of  immorality  is  committed,  and  although  it 
may  not  have  been  a  very  grievous  fault  morally  or 
socially,  yet  the  person  is  never  able  to  throw  off  the 
impression.  Thus,  a  middle-aged  single  man,  who  had 
led  an  altogether  continent  life,  on  one  occasion  ex- 
posed his  person  at  his  bedroom  window,  and  although 
no  one  seems  to  have  been  affected  by  the  exposure, 
and  although  for  some  weeks  it  made  no  impression 
upon  him  beyond  a  slight  feeling  of  having  done  an 
immodest  and  unworthy  act,  yet,  becoming  dyspeptic 
and  out  of  health,  he  began  to  be  impressed  more  and 
more  with  the  gravity  of  the  act  he  had  committed. 
He  sought  relief  by  going  to  his  religious  adviser  ;  he 
tried  by  confession,  by  charity,  and  by  general  good 
deeds,  to  wipe  out  the  evil ;  but  nothing  he  could  do  in 


Chap.  VI.]  Dysentery  and  Hypochondriasis.       149 

any  way  removed  the  anguish,  and  day  by  day  his 
grief  grew  like  a  monster  in  a  nightmare,  threatening 
to  smother  and  destroy  him.  He  had  no  loss  of  intel- 
lect, no  loss  of  reasoning  power,  had  fair  ability  to 
transact  his  ordinary  business,  but  whenever  alone  the 
same  horror  always  returned.  Such  a  case  may  seem 
unusual ;  but  I  have  seen  a  dozen  at  least  similar  in 
nearly  every  particular,  except  that  the  first  cause  has 
been  different  in  each,  but  has  been,  without  excep- 
tion, some  dirty  or  low  act  in  connection  with  the  re- 
productive organs,  the  symptoms  rarely  coming  on  at 
first,  but  growing  almost  unperceived  till  the  morbid 
condition  is  fully  established.  Where  practical,  ad- 
vising such  patients  to  learn  a  musical  instrument 
is  useful  in  distracting  the  attention  and  giving  a 
pleasant  stimulus.  Marriage  is  hardly  to  be  recom- 
mended, for  they  are  already  sufficiently  prone  to 
dwell  upon  sexual  matters,  and  being  ignorant  of  the 
physiology  of  reproduction,  are  likely  to  indulge  with- 
out restraint,  or  else,  through  nervousness,  to  feel 
impotent. 

General  far  aly  sis  of  the  insane^  with  early  syinptoms 
of  a  hypochondriacal  nature. — Thomas  F.,  married,  42, 
architect,  admitted  February,  1882.  Paternal  aunt  in 
an  asylum.  Phthisis  also  present  on  the  father's 
side.  His  illness  began  with  suspicion  and  doubt 
three  months  before  admission.  Over-study  was  given 
as  the  cause.  He  was  very  suspicious,  and  fancied  he 
was  going  to  be  hanged.  He  thought  the  room  was 
filled  with  electricity.  He  had  hallucinations  of  sight 
and  hearing.  He  complained  of  his  thoughts  and  his 
words  running  away  from  the  top  of  his  head.  He  re- 
sisted being  dressed.  He  refused  food.  He  was  full 
of  hypochondriacal  delusions  for  a  year,  then  he  slowly 
developed  fully-marked  general  paralytic  symptoms. 

General  hypochondriasis  following  dysentery.  — 
Eliza  0.,  single,  31.     No  history  of  neurosis  in  the 


150       Insanity  and  Allied  Neuroses.   [Chap.  vi. 

family.  This  patient  had  suffered  from  some  "West 
Indian  fever,  and  had  to  return  to  England  in 
consequence  of  dysentery.  She  was  extremely  ema- 
ciated and  anaemic. 

She  believed  God  communicated  with  her,  telling 
her  not  to  eat,  and  added  that  she  must  die. 

She  was  obstinate,  and  at  times  inclined  to  be 
violent  if  she  were  forced  to  take  food. 

IsTo  dysenteric  symptoms  existed,  and  no  treatment 
made  any  impression  on  her  symptoms. 

She  moaned  all  day  long  about  her  dying  state 
and  about  the  brutality  of  the  doctors  in  not  sending 
for  her  relations,  as  she  had  at  most  only  a  few  days 
to  live. 

She  understood  everything  that  was  said  to  her, 
and  her  speech  and  actions  were  coherent. 

The  one  idea  which  dominated  every  other  was 
that  of  her  coming  death,  and  no  reference  to  the  fact 
that  she  had  had  the  same  ideas  for  many  months 
past  had  any  power  with  her. 

Her  condition  being  associated  with  weakness  due 
to  a  physical  disorder  may  possibly  be  recovered 
from. 

In  similar  cases  the  patients  have  had  ideas  that 
they  had  syphilis,  small-pox,  or  some  other  contagious 
disease,  and  it  is  common  for  such  ideas  to  be  associated 
with  the  notion  that  there  was  moral  impurity  as 
well,  so  that  there  is  but  one  step  between  the  fancy 
that  the  person  is  suffering  from  syphilis  and  that  he 
is  an  unpardonable  sinner.  These  cases  have  all  the 
other  characteristics  of  the  hypochondriac,  intellec- 
tually and  morally. 

To  sum  up,  hypochondriasis  may  be  so  extreme  as 
to  require  the  removal  of  a  person  from  home  sur- 
roundings, and  may  even  require  detention  in  an 
asylum ;  the  chief  reasons  for  sending  such  persons 
to  asylums  are  the  obstinate  refusal  of  food,  or  the 


Chap,  vii.]  Melancholia.  151 

suicidal  tendencies.  Hypochondriasis  may  be  simple, 
or  more  commonly  it  is  connected  with  some  delusions 
of  a  melancholic  type. 

Hypochondriacal  insanity  may  attack  persons  of 
any  age  or  condition. 

It  may  be  the  initial  stage  of  some  other  mental 
disorder,  such  as  mania,  or  it  may  be  the  first  part  of 
the  diseased  process  in  general  paralysis  of  the  insane. 

It  may  depend  on  some  organic  disease,  such  as 
phthisis  or  renal  disease ;  or  it  may  only  be  what  is 
called  a  functional  disorder. 

It  is  curable  in  direct  proportion  to  the  acuteness 
of  the  attack,  and  to  the  general  vital  condition  of  the 
patient. 

Change  of  surroundings,  exercise,  and  good  hygienic 
treatment,  are  better  than  many  visits  of  the  doctor. 


CHAPTER  YII. 

MELANCHOLIA. 

Melancholic  conditions — Melancholia  as  a  stage  in  mental  disorder 
— Varieties :  active,  passive,  and  stupid — Development,  course, 
and  result — Relationship  of  melancholia  to  delusions. 

Melancholia  is  a  state  of  mental  depression,  in 
which  the  misery  is  unreasonable  either  in  relation 
to  its  apparent  cause,  or  in  the  peculiar  form  it 
assumes,  the  mental  pain  depending  on  physical  and 
bodily  changes,  and  not  directly  on  the  environment. 

1,  Melancholia  may  be  one  stage  in  the  mental 
disorder ;  thus,  it  may  usher  in  mania  or  general  para- 
lysis of  the  insane,  it  may  be  present  after  an  attack 
of  mania,  as  a  phase  of  reaction,  or  it  may  be  one  of 
the  stages  vcLfolie  circiolaire. 


152      Insanity  AND  Allied  Neuroses.   [Chap.  vii. 

2.  Melancholia  may  be  a  complete  process  in 
itself. 

Melancholia  varies  greatly  in  its  aspects,  just  as 
grief  causes  an  emotional  storm  in  one  person  while 
it  stuns  and  stupefies  another ;  so  the  exaggerated 
melancholy  may  be  of  an  emotional  or  of  a  dull 
lype. 

I  shall  divide  the  class  of  cases  which  come  under 
the  head  melancholia  as  naturally  as  I  can  :  1.  Into 
those  with  simiole  melancholy,  i.e.  those  in  whom  the 
misery  and  its  expression  are  simply  slight  exaggera- 
tions of  natural  states,  those  cases  in  whom  there  is 
no  real  delusion,  no  fiction  such  as  that  they  are 
ruined  or  damned.  2.  In  contrast  to  these  are 
those  suffering  from  active  insanity,  those  who,  instead 
of  suffering  in  silence,  are  constantly  bemoaning  their 
lot,  and,  with  hand-wringing  and  hair-tearing,  are 
heaping  curses  upon  themselves.  Such  cases  often 
resemble  patients  suffering  from  mania  in  aspect. 

The  cases  of  most  profound  misery  are  classed  as 
suffering  from  Tnelancholia  attonita,  or  passive  melan- 
choly. 

Grief  is  a  weight  crushing  these  patients  out  of  all 
their  social  relationships. 

They  are  the  most  miserable  to  look  at  of  all 
lunatics.  So  mindless  may  they  appear  that  they  may 
be  mistaken  for  patients  suffering  from  dementia. 

Melancholia  may  depend  for  its  existence  on  some 
delusion,  but  much  more  frequently  the  misery  gives 
rise  to  the  delusion.  A  saturated  solution  of  grief 
causes,  as  it  were,  a  delusion  to  crystallise  and  take 
a  definite  form. 

Melancholia  has  a  bodily  and  a  mental  aspect. 

Physical  symptoms. — It  is  associated  with  an 
anxious  expression  more  or  less  pronounced,  the  skin 
is  generally  sallow,  the  appetite  bad,  digestion  imper- 
fect, tongue  moist,  often  tremulous  and  fiabby,  bowels 


Chap.  VII.]  Physical  Symptoms.  153 

confined,  and  general  nutrition  impaired.  Some  di- 
gesti\'e  fault  is,  in  many  cases,  the  basis  of  the  refusal 
to  take  food,  which  is  one  of  the  most  serious  symptoms 
in  this  disorder.  The  circulation  is  feeble,  but  as  a 
i-ule  there  is  nothing  special  in  the  pulse  which  can 
be  associated  with  melancholia.  Later  I  shall  point 
out  that  melancholic  symptoms  are  not  unfrequently 
associated  with  visceral  disease ;  but  the  association  is 
not  so  frec[uent  as  to  deserve  extended  notice  here.  I 
have  known  the  volume  of  the  pulse  materially  dijSTer 
in  cases  of  recurrent  melancholia,  so  that  whereas  the 
upstroke  was  represented  by  a  quarter  of  an  inch  in  a 
period  of  depression,  it  was  represented  on  the  sphyg- 
mographic  tracing  by  nearly  half  an  inch  in  the 
interval  of  health.  Eespiration  is  generally  slowed, 
but  without  any  noteworthy  change  in  rhythm.  As 
a  rule,  the  bodily  movements  are  slow  or  monotonous, 
and  the  temperature  is  occasionally  sub-normal  ; 
frequently  it  is  maintained  at  its  ordinarj^  standard, 
or  may  in  active  melancholia  be  above  normal. 
Although  sexual  feelings  are  in  many  cases  in  abey- 
ance, yet  this  is  not  constantly  the  case.  Menstruation 
is  frequently  absent  in  women,  but  there  may  still  be 
sexual  desire,  and  in  both  men  and  women  I  have 
known  cases  of  sexual  excess  and  of  masturbation 
during  periods  of  mental  depression.  Sleeplessness  is 
one  of  the  most  characteristic  symptoms  of  this 
condition.  There  are  several  varieties  of  sleepless- 
ness, one  in  which  the  patient  is  restless,  excited,  and 
unable  to  remain  for  a  single  minute  in  one  position. 
Such  cases  belong  to  the  active  melancholic  class. 
Other  patients  will  lie  placidly  without  moving,  but 
suffering  torments  (so  they  tell  me)  from  sheer  misery, 
and  some  such  placidly  sleepless  patients  seem  to  be 
able  to  do  without  complete  loss  of  consciousness  in 
sleep  for  a  very  great  length  of  time.  They  do  not 
wear  themselves  out  as  do  the  more  active  and  restless 


154       Insanity  and  Allied  Neuroses.  [Chap.  vii. 

cases.  They  get  rest,  and  probably  there  is  some 
sleep,  although  an  unrefreshing  or  unrecognised  sleep, 
which  enables  them  to  endure  for  many  months.  I 
remember  a  patient  who  recovered  in  the  end,  but 
who  for  over  three  months  was  never  found  asleep 
once  by  the  night  watch,  who  visited  her  hourly ;  and 
on  recovery  this  patient  asserted  that  she  never  lost 
consciousness  during  the  whole  of  the  three  months. 

There  are  other  conditions  of  sleep  which  we  meet 
with  in  melancholia.  In  some  the  patients  own  they 
sleep,  but  at  the  same  time  say  that  the  sleep  is  alto- 
gether unrefreshing,  so  that  when  they  wake  up 
they  feel  no  better  than  when  they  went  to  bed. 
Another  form  of  insensibility  occurs  in  these  pa- 
tients, so  that  they  eat  or  drink  in  large  quantities, 
and  yet  without  any  feeling  of  satiety.  Lastly,  they 
may  sleep  in  a  way  which  many  have  described  as 
"  dead  sleep,"  a  condition  which  they  compare  rather 
to  syncope  than  to  ordinary  forgetfulness.  They  de- 
scribe a  sudden  plunging  into  unconsciousness,  and 
an  unexpected,  unsatisfied  return  to  wakefulness,  and 
in  these  cases  also  there  is  as  complete  a  want  of  any 
refreshing  influence  as  in  the  former  ones. 

Sensory  symptoms. — Sense  perception  in  such 
cases  is  often  dull,  and  in  some  cases  the  melancholia 
seems  directly  to  be  associated  with  impairment  or 
loss  of  one  or  more  of  the  special  senses.  I  am  con- 
stantly in  the  habit  of  referring  particularly  to  cases 
in  which  loss  of  sight  or  deafness  is  associated  with 
the  development  of  melancholic  symptoms  ;  but  gener- 
ally the  chief  change  is  one  of  dulled  perception  and 
slow  reaction.  In  a  way  this  may  be  explained  by 
the  abstraction  of  the  patient's  attention;  his  mind 
being  entirely  occupied  along  one  line  it  is  difficult 
to  attract  his  attention  in  another.  In  this  way  an 
apparent  loss  of  common  sensibility  may  occur,  so 
that  a  melancholic   patient  may  pick  his  hands  till 


Chap.  VII.]  Mental  Symptoms.  155 

they  bleed,  or  make  holes  in  his  forehead  with  his 
nails  without  seeming  to  feel  it.  The  chief  perver- 
sions of  sense,  however,  are  the  hallucinations  and 
illusions  which  are  so  common  in  these  patients. 

Probably,  next  to  delusional  insanity,  it  is  more 
common  to  meet  with  hallucinations  in  this  group  of 
m.ental  disorders  than  in  any  other.  A  very  large 
proportion  of  patients  suffering  from  melancholia  have 
sense  perversions,  and  half  of  the  dreads,  horrors,  and 
suspicions  which  fill  the  minds  of  the  patients  are  due 
to  subjective  impressions.  "  Yoices  "  are  constantly 
heard  by  night  and  by  day  threatening,  warning, 
accusing,  and  vilifying.  Visions  of  horror,  alarm,  and 
threatenings  are  conveyed  by  one  or  other  of  the 
senses,  which  keep  the  patient  ever  on  the  rack.  The 
causation  of  these  hallucinations  will  be  considered  in 
detail,  and  examples  will  be  given  later.  It  may, 
however,  be  well  to  state  here  that  hallucinations, 
although  most  common  of  hearing  and  next  probably 
of  sight,  are  still  extremely  frequent  with  common 
sensibility,  producing  the  thousand  and  one  strange 
feelings  of  so-called  magnetism,  electricity,  spiritual 
communication  or  influence,  and  the  like. 

Mental  symptoms. — In  ordinary  melancholia 
the  memory  is  good  ;  patients  accurately  recall  what 
has  taken  place  before  the  attack  ;  they  remember 
what  has  occurred  during  the  attack,  and  vividly 
recollect  the  supposed  cause  of  their  break-down, 
which  generally  to  them  appears  some  frightful  enor- 
mity or  injury  which  has  been  magnified  and  coloured 
by  their  morbidly  sensitive  condition.  I  have  several 
letters  from  patients  telling  me  they  remembered 
being  told  by  the  doctors  to  rouse  themselves,  and 
that  such  advice  had  had  an  influence  upon  them. 
They  feel  acutely  the  tones  in  which  they  are  ad- 
dressed, and  it  is  of  the  utmost  importance  that, 
though  they  should  be  spoken  to  in  a  straightforward 


156      Insanity  and  Allied  Neuroses.  [Chap.  vii. 

way,  yet  this  should  be  done  without  sneering  or 
bantering,  for  they  will  recall  an  unkindly  word  or  act 
as  well  as  a  kindly  one.  The  association  of  ideas  is 
often  natural,  and  although  the  ideas  may  seem  to  flow 
but  slowly  compared  with  those  in  the  acute  mania, 
yet  they  are  normal  in  relation  to  one  another.  Patients 
often  will  be  found  able  to  argue  perfectly  clearly  and 
connectedly  about  other  patients,  and  upon  subjects 
not  connected  with  their  own  insanity  \  but  as  soon  as 
they  are  brought  face  to  face  with  their  own  condition 
they  are  unable  to  balance  ideas.  The  patient  who 
feels  herself  a  source  of  contagion,  and  who  is  desirous 
to  be  buried  alive  to  prevent  others  being  affected  with 
the  pestilence,  is  in  no  way  convinced  she  is  wrong 
because  from  day  to  day  the  patients  around  her  do 
not  acquire  the  disease ;  yet  she  can  see  the  absurdity 
of  one  who  daily  complains  that  she  was  galvan- 
ised the  night  before,  or  of  another  who  says  the 
attendants  are  men  in  women's  clothes.  We  had  some 
little  time  ago  at  Bethlem  a  woman  possessed  by  the 
idea  that  she  had  the  itch,  and  this  idea  caused  her  to 
object  to  shake  hands  with  the  doctors  ;  and  although 
she  was  at  one  time  answered  according  to  her  folly, 
and  at  another  not  according  to  her  folly,  her  ideas 
long  remained  unchanged,  neither  reason  nor  banter 
appealing  to  her.  As  far  as  her  powers  of  judgment 
with  respect  to  the  best  mode  of  managing  a  house 
or  controlling  her  children  were  concerned,  she  was 
reasonable  enough.  She  lost  her  delusion  one  night 
suddenly. 

One  characteristic  of  the  melancholic  patient  is 
that  his  egotism  should  be  so  nearly  allied  to  that  of 
the  hypochondriac,  and  in  Edgar  Allan  Poe's  words, 
"he  is  doubting,  dreaming  dreams  no  mortals  ever 
dared  to  dream  before,"  so  that  a  patient  suffering 
from  melancholia  will  describe  himself  as  being  the  only 
one  who  has  had  such  experiences.     The  very  charm 


Chap.  VII.]      Letter  of  a  Melancholic.  157 

of  texts  in  Scripture  about  the  unpardonable  sin  is 
that  there  was  to  be  but  one  cast  away.  If  there  had 
been  hundreds  of  unpardonable  sinners  it  would  not 
have  appealed  to  the  insane  more  than  the  general 
statement  that  we  are  all  sinners,  or.  as  the  Psalmist 


A  case  of  Melancholia  with  Ecstacy. 

said  in  his  haste,  "  all  liars."  The  egotism  of  melan- 
choly is  very  well  shown  in  the  graphic  letter  whiclt 
I  insert  here  : 

"  Yous  etes  trop  bonne  envers  moi  qui  ne  merite 
pas  la  moindre  consideration.  Si  vous  pouvez  cepen- 
dant  venir  encore  une  fois  me  voir  ici  je  vous  serai 


158     Insanity  and  Allied  Neuroses.     [Chap.  vii. 

bien  obligee.  II  ne  faut  pas  attendre,  ma  chere  amie, 
que  je  retourne  dans  le  monde.  Je  suis  trop  mechante 
m^me  pour  cela,  et  si  pour  ce  monde,  alors  certaine- 
ment  pour  le  ciel.  J'ai  quitte,  d'une  maniere  la  plus 
impie,  ma  propre  position  dans  la  societe  ;  ce  ne  fut 
jamais  mon  destin  que  d'etre  ici.  Je  m'y  suis  con- 
damnee  pour  ma  seule  faute,  faute  inouie,  je  crois, 
dans  toutes  les  annales  de  la  race  humaine.  II  reste 
chez-vous  quelques  objets  qui  m'ont  autrefois  apparte- 
nus,  et  je  serais  bien  obligee  si  vous  vouliez  avoir  la 
bonte  de  les  distribuer  de  quelque  maniere  qu'il  vous 
semblera  bon.  Tant  de  jolies  choses  que  je  ne  reverrai 
jamais,  des  cadeaux  de  mes  parents  et  de  plusieurs 
amies-dehors  cheres,  tons  inutiles  a  present.  Oh  ! 
que  ne  puis-je  aller  vous  voir  comme  dans  les  temps 
passes,  et  entendre  votre  voix  douce  et  gaie  !  Vous 
avez  ete  toujours  si  bonne  et  pleine  d'amitie  pour  moi, 
et  j'ai  regrette  toute  votre  affection.  Que  n'ai-je 
suivi  votre  bon  exemple,  alors  j'aurais  ete  aussi  utile 
et  heureuse  !  Les  benedictions  du  ciel  restent  sur 
votre  tete ;  vous  etes  du  nombre  des  saintes  qui 
demeurent  dans  les  lieux  qui  seront  pleins  de  la 
gloire  et  de  la  presence  de  Dieu.  Pensez-vous  de 
temps  en  temps  a  moi,  miserable  et  seule  dans  les 
tourments  de  I'eternite,  et  sans  aucune  amie  pour 
soulager  mes  mis^res  !  Recevez  I'assurance  de  mon 
amitie,  mais  c'est  une  amitie  pleine  de  regret, 

Yotre  mal-heureuse 

Eleonore." 

The  correlative  of  egotism  is  .self-consciousness; 
and,  as  some  have  described  it,  the  melancholic  seems 
"wrapped  "up  in  himself;  and  this  idea  of  "self- 
wrapping  "  is  a  good  one,  and  describes  the  condition 
admirably.  It  is  impossible  to  define  the  boundary 
between  the  melancholic  patient,  and  the  one  who, 
from   exaggeration   of    self-feeling,    has   become   the 


Chap.  VII.]  Religious  Mania.  159 

delusional  lunatic  ;  for  although  the  general  bodily 
and  mental  symptoms  of  the  latter  differ  materially 
from  those  of  the  former,  yet  they  are  but  variable 
developments  from  a  similar  stock.  In  the  one, 
the  growth  and  development  of  ideas  has  gone  on 
under  a  morbid  influence,  so  that  the  growth,  like  that 
of  a  plant  growing  in  a  cellar,  may  be  considerable 
and  varied,  but  yet  with  an  unhealthy  colour  in 
every  fibre,  whereas  the  other  has  ceased  to  develop, 
but  remains  preserved  in  all  its  grim  horror  by  its 
dark  surroundings. 

Other  points  connected  with  the  egotistical  and 
self-conscious  side  are  the  ideas  of  moral  and  physical 
change  and  perversion.  Patients  describe  themselves 
as  being  unnatural,  as  having  lost  all  power  of  human 
love  ;  they  believe  themselves  to  be  ruined,  and  to  be 
the  causes  of  misery  to  those  around  them  ;  or  they 
may  be  crushed  by  the  dread  of  an  impending  sorrow. 
I  often  think  that  the  priest  of  Apollo  Laocoon 
well  represents  the  unpardonable  sinner,  and  that  the 
sword  over  the  head  of  Damocles  marks  but  the 
feeling  of  impending  fate  as  felt  by  the  patient 
suffering  from  melancholy. 

Two  other  prominent  symptoms  are  associated  in 
the  public  mind  with  melancholia.  The  one,  religious 
mania  so-called,  and  the  other,  suicidal  tendencies.  I 
have  referred  (see  page  50),  under  the  head  of  causation 
of  insanity,  to  the  relationship  of  religious  move- 
ments to  inyanity,  and  I  would  repeat  the  statement 
that  religion  rarely  produces  insanity,  but  constantly 
colours  it.  It  may  be  said  that  the  very  fact  of  its  oc- 
curring so  frequently  as  a  symptom,  and  having  some 
relationship  as  an  exciting  cause,  are  sufficient  evi- 
dences that  it  is  an  important  element  in  the  produc- 
tion of  the  disorder.  But  I  would  reply  that  the  gun- 
cotton  requires  but  a  light,  it  matters  not  whether 
it    comes  from  an  electric   spark,    a    steam  -  engine_, 


i6o    Insanity  and  Allied  Neuroses.     [Chap.  vii. 

or  a  silent  match.  The  real  explanation  of  the  im- 
mense number  of  cases  with  religious  ideas,  suffering 
from  melancholia,  is  that  religion,  being  an  unde- 
fined environment  of  man,  lends  itself  readily  to  the 
explanation  of  the  unknoAvn.  Religion  begins  by 
formulating  a  series  of  dogmata  which  can  in  no  way 
be  dispi'oved,  and  its  followers  are  taught  that  they 
are  to  judge  of  their  relationship  to  the  great  ques- 
tions, not  so  much  by  their  actions  as  by  their  feelings. 
What  wonder  is  it,  then,  that,  having  strange  feelings 
which  they  have  never  before  experienced,  they  should 
infer  that  these  are  only  to  be  explained  on  religious 
grounds  %  It  does  not  matter  much  what  the  previous 
education  of  the  patient  has  been.  I  have  known  a 
man  who  for  twenty-five  years  led  the  life  of  a  cul- 
tured atheist ;  a  man  whose  whole  energies  were 
developed  for  self -gratification  in  every  way ;  who 
was  refined  by  his  knowledge  of  ancient  and  modern 
literature,  and  by  a  constant  intercourse  with  the 
world,  yet,  on  becoming  melancholic,  he  subsided  into 
an  emotionally  religious  man,  appealing  to  all  whom 
he  met  to  look  after  the  welfare  of  their  souls,  be- 
lieving himself  to  be  cast  away  for  ever. 

It  is  needless  now  to  enlarge  further  on  the  so- 
called  "  religious  mania,"  as  it  will  be  seen  that  in 
the  great  majority  of  cases  referred  to  this  group, 
there  is  only  a  strong  tendency  to  explain  their 
misery  by  means  of  some  text  or  religious  dogma  ; 
for  instance,  one  patient  who  was  desperately  suicidal 
and  also  homicidal,  believed  that  he  was  destined  to 
be  the  second  Judas  Iscariot,  and  would  have  to  pass 
through  the  same  course  as  his  prototype  when  mil- 
lennium was  at  hand.  This  last  patient  was,  as  I  say, 
not  only  suicidal,  but  homicidal.  As  a  rule  there  is 
much  greater  danger  from  suicide  in  these  cases  than 
from  homicide ;  but  as  it  is  impossible  accurately 
to  gauge  the  motives  of  an  insane  person,  it  would  be 


Chap.  VII.]  Suicidal  Tendencies.  i6i 

daDgerous  to  say  that  simply  because  a  man  is  strongly 
suicidal  he  is  not  likely  to  be  homicidal  also.  It 
might  be  said  that  a  man  who  believed  himself  to  be 
Judas  Iscariot  would  have  no  reason  to  wish  to  kill  any 
one  but  Christ ;  but  this  very  man  determined  and 
attempted,  on  two  occasions,  to  kill  me,  without  being 
able  to  give  any  other  reason  than  that  he  would  be 
no  worse  off  in  the  future  state  whether  he  killed  me 
or  not.  This  is  a  good  example  of  the  difficulty,  if 
not  impossibility,  of  calculating  on  the  actions  of  an 
insane  person,  though  in  many  respects  he  may  appear 
to  be  nothing  beyond  a  monomaniac. 

Suicidal  tendencies  may  arise  from  very  different 
causes,  just  as  the  attempt  may  be  made  in  very 
different  ways.  It  is  strange,  in  reference  to  this  last 
point,  that  suicidal  patients  should  have  favourite 
methods  of  putting  an  end  to  their  lives,  and  that 
they  will  even  incur  danger  in  order  to  accomplish 
their  end.  In  this  way  I  have  known  a  patient  ex- 
tremely well-behaved  while  at  our  convalescent  home, 
who  appeared  to  have  forgotten  all  about  his  desire  to 
kill  himself  until  he  was  discharged,  when,  avoiding 
river  and  railway,  he  blew  his  brains  out  with  a 
revolver,  having  first  attempted  to  kill  himself  in  this 
manner  before  his  admission  into  the  hospital.  It  is 
narrated  also  that  a  patient  escaped  from  an  asylum 
and  swam  a  river,  and  then  threw  himself  under  a 
railway  train.  The  monotony  of  their  thoughts  thus 
persists  and  shows  itself  even  in  attempts  at  self- 
destruction.  Patients  may  commit  suicide  to  get 
rid  of  the  bodily  or  mental  misery  from  which  they 
suffer ;  it  is  thus  with  certain  hypochondriacs ;  they 
may  commit  suicide  because  they  believe  themselves 
too  bad  to  live,  or  because  they  think  their  influence 
is  spiritually  or  physically  contaminating.  They  may 
kill  themselves  because  "  voices  "  urge  them  to  do  so,  or 
tell  them  they  are  too  cowardly  to  dare  to  die ;  ideas 
L— 14 


1 62         Insanity  AND  Allied  Neuroses.  [Chap.vn. 

of  being  followed  or  persecuted  often  cause  suicide ; 
patients  may  achieve  the  same  end  because  they 
believe  they  have  to  bear  the  sins  and  sorrows  of  the 
world ;  or  believing  they  are  already  dead,  or  so 
utterly  changed  and  unnatural,  they  consider  that 
throwing  themselves  into  the  river  is  but  getting  rid 
of  a  dead  and  decaying  body.  The  dread  of  vivisec- 
tion and  the  horror  of  hearing  the  cries  of  their  re- 
lations, who  they  think  are  being  tortured,  make 
patients  desperately  suicidal. 

It  is  difficult  to  give  every  possible  cause  or  idea 
which  may  lead  to  suicide.  The  above,  however, 
point  out  sufficiently  the  chief  causes  which  may  give 
rise  to  attempts  at  suicide  in  patients  suffering  from 
melancholia  ;  for  it  must  be  remembered  that  patients 
may  kill  themselves  when  suffering  from  other  forms 
of  mental  disease  as  well  as  melancholia.  The  maniac 
may  throw  himself  from  a  height,  because  he  believes 
that  angels  bear  him  up  ;  or  the  general  paralytic, 
with  all  his  fulness  of  happiness,  may  cause  his  own 
death  in  his  attempt  to  show  his  immortality. 

Melancholia  having  now  been  considered  generally 
in  its  bodily  and  mental  aspects,  and  having  been  sub- 
divided into  convenient  groups,  it  remains  for  me  to 
describe  more  fully  its  general  pathology  and  aetiology, 
its  course  and  the  results  followins:  it. 

Melancholia  may  be  the  mental  side  of  bodily 
disease.  In  certain  temperaments  change  in  the 
nutrition  of  the  brain  depending  on  some  general  or 
local  disease  may  set  up  mental  pain.  The  mental 
machine  no  longer  acting  smoothly,  there  is  friction 
and  imperfect  action. 

Melaiicliolia  is  common  in  conditions  of  phy- 
sical weakness  apart  from  organic  disease. 

[Exhaustion,  or  drain  on  the  nervous  system, 
may  set  up  the  disordered  process. 

Not  only  is  direct  drain  a  cause  of  melancholia, 


Chap.  VII.]  Exhaustion.  163 

but  any  cause,  bodily  or  mental,  which  worries  the 
body  or  the  mind,  any  cause  which  by  its  constancy, 
or  by  its  frequent  repetition,  gives  no  chance  of  repair, 
may  also  cause  melancholia. 

In  some  cases  toxic  materials  in  the  blood  will  act 
in  the  same  way. 

Just  as  mania  was  pointed  out  to  be  a  condition 
of  weakness  with  loss  of  control,  so  melancholia  is  a 
state  of  painful  self-conscious  weakness. 

Melancholia  may  in  its  course  be  progressive, 
passing  from  a  vague  feeling  of  inexplicable  unhappi- 
ness  through  a  stage  of  more  profound  misery  to  one 
of  the  deepest  woe. 

Melancholia  may  consist  of  a  series  of  fits  of  de- 
pression of  greater  or  less  intensity  separated  by 
periods  of  mental  health. 

As  I  have  already  stated,  melancholia  may  be 
the  initial  stage  of  any  form  of  mental  disorder. 

Melancholia  may  suddenly  pass  off,  or  it  may 
gradually  clear  up. 

In  most  cases  the  recovery  from  melancholia  is 
associated  with  improvement  in  general  health. 

Slow,  steady  recovery  is  especially  common  in 
young,  otherwise  healthy,  people,  and  in  those  in 
whom  the  melancholy  has  been  but  an  exaggeration 
of  a  natural  physical  or  moral  depression.  Thus  it 
was  with  a  man  who  slowly  became  possessed  by  the 
idea  that  he  had  been  the  cause  of  his  late  wife's 
death,  and  who,  in  consequence,  was  sleepless,  suicidal, 
and  lachrymose  for  weeks ;  but  when  he  began  to  sleep 
better  and  to  assume  a  more  healthy  aspect  bodily 
and  facially  he  began  to  lose  these  ideas,  and  men- 
tally and  physically  became  well.  In  other  cases,  the 
attacks  of  depression  go  and  come  for  a  time,  gradu- 
ally becoming  more  pronounced,  and  in  such  cases  con- 
siderable risk  is  run  and  fatal  accidents  occur.  Thus, 
a    woman  I  once  saAv  in  the  country  was    suffering 


t64         Insanity  and  Allied  Neuroses.  [Chap.  vii. 

from  mental  depression  that  had  followed  the  death 
of  her  husband,  which  left  her  in  poor  circum- 
stances. She  was  living  in  a  solitary,  out-of-the-way 
house.  She  was  depressed '  for  some  days,  and  then 
set  about  her  household  duties  as  before.  Again  de- 
pression came  on,  and  her  friends  grew  alarmed.  I 
saw  her,  and  warned  them  of  the  danger  of  leaving 
her  alone.  The  magistrate  was  informed  of  her  con- 
dition^ but  when  he  visited  her  she  was  again  quiet, 
and  he  declined  to  act  in  the  matter.  Within  a  week 
after  she  hanged  herself  in  the  barn.  In  such  cases, 
in  women,  it  is  particularly  noteworthy  that  the  chief 
danger  occurs  about  the  menstrual  periods.  Cases 
with  recurrences  of  this  kind,  if  treated  sufficiently 
early,  may  go  through  the  inverse  process,  having 
slighter  recurrences  at  longer  intervals  till  they  com- 
pletely recover. 

Some  cases  recover  suddenly,  and  these  cases  are 
even  more  difficult  to  explain  than  similar  ones  met 
with  in  acute  mania  and  hysteria.  I  have  known  a 
patient  with  melancholia  with  delusions,  fall  asleep, 
and  wake  up  to  find  the  cloud  gone.  And  I  have 
known  a  person  convinced  of  the  faithlessness  of  his 
wife,  who  had  constructed  a  whole  romance  of  cir- 
cumstantial evidence  which  completely  misled  me  into 
believing  that  it  was  possible  that  he  was  after  all 
rather  sinned  against  than  deluded,  lose  the  whole  of 
this  airy  fabric  when  leave  of  absence  was  granted  to 
him  and  his  home  environments  were  re-established. 
Not  only  may  delusions  pass  off  suddenly,  but  the 
gloom  of  melancholy  may  also  lift  itself  as  a  cloud 
from  a  valley.  One  patient,  who  was  in  Bethlem  for 
fifteen  months,  although  standing  like  a  veritable  statue 
of  woe,  neither  speaking  nor  eating,  nor  allowing 
anything  to  be  done  for  him  during  that  time,  yet 
when  being  removed  as  "  uncured  "  from  the  asylum, 
suddenly  woke  up,  conversed  freely,  and   remained 


Chap.  VII.]        Delirious  Melancholia.  165 

well  for  twelve  years,  after  the  lapse  of  which  time 
he  was  brought  back  to  Bethlem  in  a  similar  con- 
dition. Having,  however,  become  wiser  by  former 
experience,  we  did  not  on  this  occasion  allow  him  to 
become  mentally  rigid  ;  but  by  means  of  sending  him 
for  drives,  and  for  a  few  hours  at  a  time  restoring  his 
home  associations,  we  were  enabled  a  second  time  to 
discharge  him,  and  this  time  as  "cured."  I  shall 
give  other  examples  of  the  more  or  less  sudden  cures 
which  may  occur  in  melancholia. 

Others  may  pass  from  melancholy  with  stupor  as 
an  active  disorder^  into  a  state  of  stolid  misery,  in 
which  the  miserable  aspect  is  rather  the  indication  of 
the  misery  which  has  been  felt  than  an  index  to  the 
feelings  at  the  time. 

Melancholia  may  end  in  secondary  dementia,  and 
in  all  large  asylums  there  are  sure  to  be  found  many 
patients,  often  useful  helps  in  the  wards,  who  have 
passed  through  attacks  of  mental  misery.  Such 
patients  may,  in  their  weak-minded  state,  show  no 
signs  of  their  old  disorder  or  of  their  old  delusions  ; 
they  may  show  few  or  many  scars  as  the  result  of  the 
fights  they  have  passed  through  ;  and  yet,  from  their 
simple  silly  condition,  it  is  impossible  to  say  what 
was  the  nature  of  the  first  attack,  whether  maniacal 
or  melancholic. 

Melancholia  often  ends  in  death.  A  certain 
number  of  young  cases  die  of  "  broken  heart ; "  and 
I  suppose  the  best  way  of  describing  this  mode  of 
death  is  to  call  it  simple  melancholia.  In  my  ex- 
perience, it  is  not  uncommon  to  meet  with  cases  similar 
to  those  dying  of  acute  delirious  mania  in  this  class. 

Acute  delirious  melancholia  has  already  been  re- 
ferred to  in  a  case  given  at  page  95. 

In  this  condition  the  general  symptoms  closely 
resemble  those  met  with  in  acute  delirious  mania. 
The  patients  are  often  highly  unstable  from  nervous 


i66  Insanity  and  Allied  Neuroses.  [Chap.  vii. 

inheritance.  Moral  causes,  such  as  grief  or  love 
affairs,  act  as  powerful  causes.  There  are  sensory- 
perversions,  such  as  partial  anaesthesia  and  colour 
blindness.  Ovarian  tenderness  is  commonly  present 
with  menstrual  irregularity.  The  bodily  temperature  is 
above  normal,  the  tongue  dry  and  brown,  and  food  is 
refused.  The  condition  approaches  that  of  typhoid. 
Neglect  of  personal  appearance,  and  apparent  forget- 
fulness  of  friends  and  surroundings,  all  complete 
the  parallelism  between  the  two  states  ;  only  in  acute 
delirious  melancholia  mental  depression  is  present. 
Rapid  death  or  recovery  follow. 

Patients  admitted  into  Bethlem  every  year  in  con- 
siderable numbers,  refusing  food,  obstinate,  nervous, 
and  suspicious,  often  die,  notwithstanding  care  and 
constant  feeding,  of  some  bodily  disease  other  than 
that  of  the  brain. 

These  are  often  young  girls  who  refuse  food 
because  they  are  unworthy^  or  because  they  feel  un- 
natural. In  these  cases  there  is  often  lung  disease, 
which  may  be  the  cause  of  the  whole  of  the  mental 
disorder,  or  I  believe  that  the  impaired  nervous  state 
may  lead  to  low  forms  of  inflammation  of  the  lungs 
which  end  fatally. 

I  have  met,  too,  with  tubercular  disease  of  the 
kidneys  and  other  visceral  diseases  in  similar  cases. 
In  an  old  man  who  was  admitted  with  profound 
melancholia,  and  with  the  idea  that  he  was  dying, 
and  therefore  ought  not  to  be  cared  for,  we  found 
there  was  old  peritonitis  due  to  perforation  of 
appendix  cseci,  which_,  without  giving  rise  to  any  phy- 
sical signs,  had  caused  the  production  of  half-a-gallon 
of  pus.  Other  cases  of  melancholia  die,  and  their 
symptoms  really  de^^end  on  the  changes  due  to 
general  paralysis  of  the  insane,  which  has  not  been  re- 
cognised owing  to  the  silence  and  the  obstinacy  of  the 
patient. 


Chap.  VII.]  Simple  Melancholia.  167 

So  that  I  end  this  part  as  I  began  it,  by  repeat- 
ing that  melancholia  may  be  the  mental  symptom 
of  bodily  disease. 

Special    forms    of    inelancliolia.  —  Simple 

melancholia. — It  is  of  the  utmost  importance  that 
mental  disorders  should  be  recognised  as  early  as 
possible,  and  in  studying  the  condition  which  I  have 
called  simple  melancholia,  I  shall  insist  on  the 
necessity  of  recognising  it  as  a  stage  of  disorder 
which,  if  neglected,  may  become  chronic  and 
incurable. 

I  have  described  a  group  of  cases  under  the  head 
of  acute  mania,  in  which  the  chief,  if  not  the  only 
symptoms  were  slight  alteration  in  the  social  relation- 
ships of  the  individual;  and  under  melancholia  I  must 
place  those  with  slight  perversions  of  feeling  and 
intellect  of  a  gloomy  nature.  In  the  former  men 
acted  in  an  eccentric  way,  so  that  those  who  had 
been  steady  and  industrious  became  amorous  and 
given  to  drink  and  self-indulgence.  With  the 
simply  melancholic  patients,  we  meet  with  every 
shade  of  depression,  which  may  be  dependent  either 
upon  some  traceable  bodily  disease,  such  as  phthisis, 
or  may  arise  from  some  bodily  disorder.  The 
patients  to  whom  I  refer  very  commonly  have 
insane  relations,  and  are,  in  fact,  already  unstable. 
Such  cases  are  very  commonly  met  with  in  the 
young  of  both  sexes ;  but  they  also  occur  in  middle 
and  advancing  life  in  patients  who  are  doing  their 
life's  work  energetically  and  well.  It  is  common 
for  physicians  to  be  consulted  for  symptoms  of 
melancholia  by  active-minded  busy  men,  who  have 
really  exhausted  themselves  by  over- strain  rather 
than  by  over-work ;  and  many  such  cases  not  only 
recover,  but  live  to  rise  nearly  to  the  top  in  their  re- 
s])ective  professions  ;  though  as  a  rule  their  mental 
tlaw   prevents  the   very    best    being    done    by   them. 


i68  Insanity  and  Allied  Neuroses.  [Chap.  vii. 

Melancholic  depression  of  this  kind  aflfects  each  in- 
dividual differently  ;  some  are  wretched,  being  occu- 
pied with  their  own  feelings  of  misery,  but  without 
delusions.  They  resemble,  in  many  points,  the  ordi- 
nary hypochondriac,  save  that  they  are  more  content 
to  be  left  alone,  and  are  not  desirous  of  pouring  their 
woes  into  every  ear  ;  and  their  woes  are  mental,  not 
bodily. 

The  younger  cases  begin  much  in  the  following 
way  :  A  young  man  of  about  twenty  years  of  age, 
having  entered  some  business  or  calling  without  any 
definite  desire  to  follow  that  avocation,  sticks  to  it 
conscientiously  for  a  time,  but  without  the  interest 
and  enthusiasm  which  is  natural  to  youth.  He  often 
takes  to  brooding  and  vdshing  he  was  something  else  ; 
but  family  requirements  keep  him  where  he  is.  He 
is  at  the  same  time  leading  a  quiet  and  unhealthily 
reserved  life.  When  away  from  work  he  has  no 
special  hobby,  and  drifts  into  idle  speculations.  If 
he  happen  to  have  indulged  in  masturbation  he  be- 
comes worse  ;  he  takes  a  long  time  in  undressing  and 
getting  into  bed,  and  is  equally  long  in  rising  and 
washing  in  the  morning.  He  displays  a  want  of 
crispness  and  energy  in  every  act  which  is  not  auto- 
matic. '  He  frequently,  at  this  time,  takes  to  reading 
theological  and  medical  books,  and  some  morning 
astonishes  his  friends  by  an  outburst  of  tears,  or  by 
marked  irritability  and  change  in  his  temper.  He 
may  make  some  attempt  to  throw  off  the  bondage 
which  he  feels  holding  him,  but  unless  his  condition 
be  recognised  and  his  surroundings  entirely  changed, 
he  will  probably  pass  into  a  more  profound  stage  of 
melancholy.  He  feels  weak,  disgusted  with  himself, 
and  thinks  that  he  is  unlike  other  youths,  and  that 
there  must  be  something  radically  wrong  because 
he  has  no  feelings  of  sympathy  or  love  for  any  one  in 
the  world.     He  may  express  himself  as  feeling  dead. 


ch:^p.  VII.]  Simple  Melancholia.  169 

Such  patients  will  frequently  make  a  confidant  of  the 
doctor,  and  express  every  anxiety  to  recover,  but  at 
the    same  time    acknowledge  themselves    unable   to 
make  an  effort.     There  is  but  one  method  of  treat- 
ment for  such  cases.      For  a  time  let  them  be  rooted 
up  and  allowed  to  move  from  place  to    place,  or  if 
means  are  wanting,   let   some   change  of    occupation 
be  sought ;  I  would  also  recommend  some  mechanical 
occupation,  such  as  work  at  the  bench,  on  the  farm, 
or  such  like.     Yoyages  are  undoubtedly  serviceable ; 
but  then  there  is  always  some  risk  that  these  patients 
may  become  suicidal,  and  therefore  it  would  be  un- 
wise to  send  them  to  sea,  unless  under  careful  charge. 
Occupation,    interest,    and    change,    associated    with 
cold    baths,    sea-bathing,    regular  muscular    exercise, 
and  a  liberal   diet   with    stimulants    taken    with   the 
meals,  frequently   produce    beneficial  results.     It  is, 
however,    of    great    importance    to    remember^    that 
as  this  morbid   condition   has  been   slowly  establish- 
ing itself,  so  it  cannot  be  expected  to  pass  off  very 
rapidly,  and  a  period  of  from  four  to  twelve  months 
is  necessary  to   effect  a  cure.      If  the  case,   instead 
of  improving,    become    worse,    we   have   an  example 
of    a   form    of    simple   insanity,    which    may    require 
asylum  treatment ;  for  these  cases  should  not  at  first 
be    sent    to    asylums,    treatment    in   the    homes    of 
medical  men  or  of  tutors  being  preferable.      As  soon 
as  a  young  patient  threatens  to  commit  suicide,  it  is 
time  to  consider  the  question  of  removing  him  to  an 
asylum.      The  other  symptom  which  often  necessitates 
the  seclusion  of  such  patients  is  that  of  refusing  food. 
Further  examples  of  the  class  simple  melancholia 
are   found  in  young  girls  who  come  into  the  asylum 
with  the  very  worst  of  characters   as  far  as  suicidal 
tendencies  are  concerned.     I  must  own  that  there  is 
much   more    cry    than   wolf,   in  my  experience ;    for 
although  I  have  seen  at  least  a  hundred  such  cases, 


170  Insanity  and  Allied  Neuroses.  [Chap.  vii. 

one  half  of  wliom  have  been  said  to  have  attempted 
suicide  even  while  in  the  hospital,  the  attempts  were 
about  as  futile  as  those  of  the  hysterical  girl.  We 
admit  patients  of  this  kind,  who  at  once  set  to  work 
to  pick  a  hole  in  a  vein  with  a  pin,  to  choke  them- 
selves with  a  i^ocket-handkerchief,  to  drown  them- 
selves by  holding  their  faces  in  a  wash-basin,  or  even 
attempt  self-destruction  by  what  they  call  swallowing 
their  tongue.  I  would  not  willingly  throw  the  at- 
tendants on  such  cases  ofl'  their  guard,  but  I  would 
here  register  my  experience  that  suicide  in  such  cases 
is  very  rarely  effected. 

In  these  young  women  there  is  either  restlessness 
and  inability  to  work,  or  stolid  indifference ;  they  are 
sallow  in  complexion,  the  tongue  is  tremulous,  often 
flabby  and  coated,  appetite  bad,  food  often  refused, 
bowels  confined,  circulation  feeble,  and  menstruation 
absent.  Tonics,  change,  and  exercise  cure  the 
majority  of  such  cases. 

Sex  influences  the  aspect  of  these  cases  of  simple 
melancholia.  They  pass  gradually  into  those  suffering 
from  more  severe  types  of  melancholia,  and  those 
in  whom  delusions  exist,  and  I  shall  consider  some 
cases  which  may  be  looked  upon  as  connecting  links 
in  the  chain  of  disorder. 

Among  men  we  meet  with  patients  whose  misery 
has  become  excessive,  though  unassociated  with  de- 
lusion ;  they  may  be  desperately  suicidal  from  sheer 
distress,  or  they  may  feel  driven  to  do  insane  acts 
through  what  they  call  "influence."  They  are  weak 
of  will,  and  are  driven  like  a  leaf  on  a  rapid  stream. 

Simple  melancholia  passing  into  m^elancholia  with 
delusions.  Eemissions,  recovery. — W.  H.,  single,  aged 
nineteen.  No  insanity  in  his  family,  but  phthisis 
killed  several  on  his  father's  side.  He  had  a  first 
attack  when  seventeen,  but  recovered,  and  has  been 
well  since.     Masturbation,  if  not  the  cause,   was  an 


Chap.  VII.]         Suicidal  Melancholia.  171 

early  symjDtom  of  the  disease.  Two  months  before 
admission  he  became  irritable  and  lazy,  and  woidd  not 
get  up  in  time  for  his  business.  He  complained  of 
pains  at  the  top  of  his  head.  He  became  stolid, 
but  without  delusions.  He  refused  food,  was  rest- 
less and  sleepless.  His  expression  was  dull.  Slowly 
he  developed  the  idea  that  he  had  committed  the  un- 
pardonable sin.  He  had  visions  and  hallucinations 
of  hearing  and  of  taste.  He  believed  he  was  going 
to  die.  Pupils  widely  dilated  ;  extremities  cold.  On 
admission  he  was  obstinate,  and  neglected  his  bladder 
and  bowels ;  his  expression  was  dull  and  his  general 
health  feeble. 

He  had  to  be  fed  with  the  stomach  pump,  and 
was  constantly  wet  and  dirty.  He  began  to  take  his 
food  within  a  week,  and  in  two  weeks  had  begun 
to  show  signs  of  returning  sanity  ;  in  three  weeks 
he  appeared  well,  but  a  month  from  admission  he 
once  more  passed  into  a  state  of  melancholia,  from 
which  he  again  recovered.  These  recurrences  were  of 
slighter  degree,  till  in  the  end  he  was  discharged  well 
for  the  second  time. 

Such  a  case  resembles  those  already  described,  in 
which  the  patients  oscillate  between  acute  mania  and 
health  for  some  time  before  they  become  stable.  Ad- 
vantage should  always  be  taken  of  the  periods  of 
health  to  try  change  in  the  surroundings,  although 
relapses  may  occur. 

Example  of  destructive  and  suicidal  excitement  in 
a  youth.  Recovery. — A  lad  of  twenty  years  old,  who 
was  brought  up  purely  at  home  among  female  rela- 
tions, developed  habits  of  self-contemplation  and  of 
masturbation,  which  rendered  him  weak,  nervous, 
emotioual,  and  unfit  for  his  ordinary  avocations.  He 
gave  way  to  several  emotional  storms,  in  one  of 
which  ho  destroyed  a  good  deal  of  furniture,  and 
seriously  lacerated  his  hands.     He  was  admitted  into 


172         Insanity  and  Allied  Neuroses.  [Chap.  vii. 

Bethlem  tied  hand  and  foot,  with  the  usual  history 
that  he  must  not  be  left  a  minute.  For  a  few  days 
he  was  very  much  excited,  and  gave  way  to  mastur- 
bation to  an  excess.  Besides  this,  he  was  dirty  in  his 
bedroom,  and  on  one  occasion  he  drank  the  contents 
of  his  chamber.  When  spoken  to  he  said  he  was 
obliged  to  do  this,  but  he  declared  that  no  voices  or 
other  indications  from  without  made  him  act  as  he 
did,  but  that  he  "felt  he  must."  It  is  common  to 
meet  with  weakly  cases  who  say  they  are  influenced; 
they  feel  that  when  doing  a  thing  they  do  not  them- 
selves exercise  any  volition.  By  means  of  employment 
and  getting  him  interested  in  his  old  occupations  and 
amusements,  among  which  were  music  and  chess,  he 
rapidly  regained  general  tone,  and  passed  into  a  state 
of  convalescence. 

Among  women  we  meet  with  very  similar  cases, 
such  as  the  following :  An  artist's  daughter,  whose 
education  had  been  somewhat  irregularly  carried  on, 
whose  physical  development  was  feeble,  and  whose 
inheritance  was  neurotic,  at  the  age  of  twenty  became 
disturbed  in  mind  and  body.  Menstruation  ceased 
to  be  regular,  her  appetite  failed,  she  slept  badly, 
and  became  indolent,  irritable,  and  restless.  The 
symptoms  slowly  increased.  She  fancied  herself  un- 
worthy to  live,  a  disgrace  to  her  family,  and  one  who 
was  bound  to  cause  harm  to  her  relations.  She  was 
convinced  that  she  was  unnatural  in  mind  and  body  ; 
that  she  was  without  natural  affection  for  God  or 
man,  and  that  it  was  but  wasted  kindness  in  her 
friends  to  try  and  "  cure  her."  A  complete  change 
in  the  surroundings,  a  regular  diet,  and  constant 
exercise,  with  medical  treatment  of  the  amenorrhcea, 
produced  great  improvement  in  her  physical  con- 
dition, and  the  mental  cloud  thinned  away,  till  it  dis- 
appeared altogether,  leaving  her  once  more  a  bright 
and  happy  girl. 


Chap.  VII.]  Simple  Mela  ncholia  .  173 

It  would  be  useless  to  enlarge  much  more  upon 
such  cases,  it  being  acknowledged  that  a  certain 
number  may  be  treated  at  home  ;  that  more  may  be 
treated  in  a  private  house  where  complete  separation 
from  relations  is  ensured,  and  others  must  be  sent  to 
asylums  and  hospitals,  either  because  the  home  circum- 
stances are  not  suitable  for  their  treatment,  or  the 
patient's  condition  from  suicidal  tendencies  or  refusal 
of  food  necessitates  extra  and  skilled  care. 

Cases  of  simple  melancholia  may  occur,  as  T  have 
said,  in  middle  life.  Thus  a  strong  vigorous  man,  who 
had  engaged  in  some  fresh  speculations,  involving  the 
greater  part  of  his  fortune,  found  that  the  venture 
was  not  so  successful  as  he  expected.  He  was  dis- 
tressed at  the  thought  that  his  newly-married  wife 
might  have  to  face  difficulties,  if  not  poverty.  These 
causes  started  sleeplessness  and  a  tendency  to  worry  ; 
his  appetite  failed,  and  he  suffered  from  dyspepsia 
and  constipation.  For  a  time  he  took  to  keeping 
a  bottle  of  sherry  in  his  office,  and  supported  him- 
self by  nips,  till,  having  over-drawn  his  physical 
account,  he  failed  utterly,  and  his  wife  and  friends 
were  alarmed  to  find  him  collapsed  as  it  were,  and 
unable  to  rouse  himself  from  his  chair.  No  vital 
interest  and  no  affection  seemed  to  exist  in  him,  He 
neglected  important  business,  and  irritably  refused  to 
be  fed  or  to  be  doctored.  Certain  threats  of  suicide 
rendered  it  necessary  that  he  should  be  watched,  and 
a  very  few  weeks  of  removal  from  home,  with  careful 
medical  and  general  treatment,  restored  him  to  his 
family,  among  whom  he  has  since  lived,  and  continues 
to  follow  his  occupation. 

In  another  case  a  woman,  who  had  had  a  large 
family  rather  rapidly,  passed  into  a  weak  physical 
condition,  having  no  appetite  and  sleeping  badly.  She 
talked  in  such  a  veiy  casual  way  about  self-destruc- 
tion, and  her  want  of  affection  for  her  children,  that 


174         Insanity  and  Allied  Neuroses.  [Chap.  vii. 

her  friends  became  alarmed,  and  a  doctor  who  saw 
her  recommended  them  to  apply  for  admission  into 
Bethlem.  The  woman  with  her  husband  came  to  see 
me,  and  I  decided  that  before  sending  her  into  an 
asylum  it  would  be  better  to  try  general  treatment ; 
for  I  found  that,  associated  with  prolonged  lactation, 
there  had  followed  menstrual  irregularity,  and  finally 
amenorrhcea,  which  had  persisted  for  nine  months. 
Warning  the  friends  of  the  danger,  and  showing 
the  necessity  of  constantly  having  a  companion  with  the 
patient,  I  commenced  treatment  by  means  of  Griffiths' 
mixture.  Weeks  passed,  during  which  she  returned 
regularly,  but  although  improved  in  health  her  mind 
remained  dull  and  oppressed.  She  told  me  that  she 
went  about  her  work  like  a  machine ;  that  she  did 
not  care  what  happened  to  her  children ;  that  she  had 
no  aftection  whatever  for  them ;  that  she  understood 
one  was  at  that  time  dying  of  bronchitis,  but  she  did 
not  care.  On  a  subsequent  visit  she  said  the  child 
had  died,  and  still  she  did  not  care,  and  surely  I  must 
admit  she  was  unnatural  after  that.  Other  medicines 
were  tried  without  avail,  till  I  put  her  on  arsenic, 
which  she  continued  in  increasing  doses  for  several 
weeks ;  one  morning  she  came  into  my  room,  with 
a  completely  altered  aspect^  and  at  once  exclaimed, 
"Well,  doctor,  I  am  natural  again."  I  asked  her, 
"Since  when?"  She  replied,  "As  soon  as  I  became 
regular."  These  slighter  conditions  of  melancholia  as- 
sociated with  feelings  of  not  being  natural,  occur  very 
constantly  in  cases  of  amenorrhcea.  As  we  may  meet 
with  amenorrhcea  lasting  some  time  after  the  re- 
establishment  of  the  general  health  in  nervous  cases, 
so  simple  melancholia  may  be  the  last  symptom  to 
leave  before  the  complete  mental  recovery. 

In  older  persons  simple  mental  depression 
occurs,  associated  with  the  earlier  stages  of  senile  de- 
generation \    generally,    apathy,    indolence,    and    the 


Chap.  Vn.] 


Active  Melancholia. 


175 


dread  of  some  unknown  calamity  are  the  symptoms, 
and  the  chief  danger  is  suicide.  The  treatment  must 
be  palliative  ;  as  a  rule  there  is  little  prospect  of  perfect 
recovery  in  such  cases,   although  a  fresh  intellectual 


A  case  of  Active  Melancliolia. 

balance   may  be    established,  it  is  one  of  a  less   de- 
veloped or  complex  character. 

Active  melancliolia. — This  name  fairly  de- 
scribes the  disorder,  and  I  should  say  it  occurs  mostly 
in  women  and  men  of  middle  age,  and  of  advancing 
years.  It  is  characterised  by  restless  misery,  as  seen 
in  the  constant  picking  of  fingers,  pulling  out  of  hair, 
and  a  tendency  to  strike  or  damage    anything   that 


176  .       Insanity  and  Allied  Neuroses.  [Chap.  vii. 

appears  to  be  an  obstacle  to  its  free  exhibition.  Gene- 
rally in  these  cases  there  is  some  marked  delusion,  and 
most  commonly  this  delusion  is  connected  with  the 
idea  that  some  one  else  is  going  to  be  injured  on  her 
account.  The  delusion  may  shift  according  to  the 
surroundings ;  thus,  one  woman  now  in  Bethlem, 
when  at  home,  believed  she  would  cause  the  ruin 
and  death  of  her  relations,  and  that,  in  consequence, 
she  must  be  killed.  When  admitted,  her  idea  was 
that  the  doctor's  child  must  be  crucified  through  her, 
because  it  was  the  babe  of  Bethlehem. 

In  another  case  the  patient  moves  restlessly  about 
moaning,  and  worrying  every  one  she  comes  in  contact 
with,  because  she  thinks  her  friends  are  accused  of 
having  done  things  which  are  disgraceful,  and  she  is 
constantly  repeating  that  she  is  "  mixed,"  and  that  it 
is  not  their  fault.  In  this  way  two  years  have,  been 
passed,  and  the  only  prospect  of  recovery  lies  in  the 
fact  that  she  is  still  capable  of  being  recalled  to  her 
old  ideas,  and  can  be  induced  to  play  the  piano, 
speak  French  or  German,  and  recognise  visitors. 
Thus  there  is  a  groundwork  upon  which  an  intellectual 
fabric  may  be  re-established. 

One  young  woman  recently  admitted  into  Beth- 
lem after  her  first  confinement,  which  was  a  tedious 
and  instrumental  one,  became  deeply  melancholic 
within  two  months  of  the  birth  of  her  child,  having 
been  sleepless,  and  oppressed  by  the  idea  that  she  was 
going  to  die,  this  feeling  being  most  marked  in  the 
early  morning ;  she  became  suicidal  and  violent,  re- 
fused food,  said  she  was  inhumanly  wicked,  that  she 
had  ruined  her  husband,  and  ought  to  be  got  rid  of. 
After  admission  she  would  romp  up  and  down  the 
wards,  moaning,  and  pushing  furniture  or  patients 
about.  She  seemed  so  lost  to  sensibility,  that  she 
picked  the  greater  part  of  her  finger-nails  off  with  pins. 

The  treatment  of  this  case  was  by  repeated  small 


Chap.  VII.]  Active  Melancholia.  177 

doses  of  morpliia,  with  occasional  saline  aperients,  and 
within  six  months  she  completely  recovered,  and 
returned  to  her  home.  Many  of  these  cases  of  active 
melancholia  do  not  recover,  some  wearing  themselves 
out  rapidly  by  their  constant  sleepless  activity ;  such, 
patients  cannot  be  well  treated  out  of  an  asylum,  as 
they  are  often  violent  and  destructive,  besides  being 
hard  to  manage.  Some  pass  into  a  state  of  auto- 
matic misery,  and  in  most  asylums  such  cases  as  the 
following  are  to  be  seen. 

A  woman  was  admitted  into  Beth  1  em,  two  of  whose 
sisters  had  also  suffered  from  melancholy  ;  she  was 
forty-five  years  old,  and  single,  had  had  several 
previous  attacks  of  mental  depression,  and  when  ad- 
mitted was  suffering  from  the  most  marked  active 
melancholia  I  have  ever  seen.  She  would  keep  on 
rocking  backward  and  forward,  moaning  that  she  did 
not  know  what  to  do.  Day  by  day  this  went  on,  and 
the  tone  of  her  voice  kept  constantly  getting  harsher 
and  louder.  At  first  she  wasted,  and  it  appeared 
likely  she  would  wear  herself  out.  She,  however, 
began  to  take  food  in  abundance,  gained  flesh,  and 
slept  better.  The  prognosis  naturally  became  graver 
as  far  as  mental  relief  was  concerned,  bodily  gain 
without  mental  gain  being  generally  of  unfavourable 
import.  In  her  case  the  repetition  of  the  formula, 
"  I  don't  know  what  to  do,"  had  become  perfectly 
automatic,  and  went  on  without  distressing  her.  It 
was  noteworthy  that  on  one  occasion,  on  a  cold  frosty 
morning,  an  attendant,  more  hasty  than  considerate, 
said  to  her,  "  If  you  don't  know  what  to  do,  I  do  ;  and 
if  you  make  much  more  noise  I  shall  send  you  out  in 
the  grounds."  The  patient,  without  any  change  in  her 
expression,  lowered  the  tone  of  her  complaint,  and  for 
the  rest  of  her  stay  never  returned  to  the  trying 
pitch  of  her  first  wail.  After  many  years  she  is  still 
the  same. 

ivi-14 


i7vS     Insanity  and  Allied  Neuroses.   [Chap.  vii. 

Some  patients,  suffering  from  active  melancholia, 
have  hallucinations  of  hearing  or  of  sight ;  but  I  should 
say  in  the  majority  of  cases  they  have  simple  delusions 
arising  from  the  feelings  of  melancholy.  Such  cases 
may  be  suicidal ;  but  I  do  not  consider  these  nearly  so 
likely  to  injure  themselves  as  the  more  stolid  cases  to 
be  referred  to  later.  No  general  treatment  can  be  re- 
commended for  all.  In  the  younger  cases,  suitable 
tonics,  such  as  arsenic,  zinc,  and  iron,  with  stimulants, 
a  liberal  diet,  and  exercise,  are  most  beneficial.  I  do 
not  often  use  morphia,  bromide  of  potassium,  or 
chloral  hydrate  in  these  cases,  but  in  older  cases,  and  in 
those  connected  with  the  climacteric,  T  find  morphia  by 
mouth  or  subcutaneously,  in  repeated  and  increasing 
doses,  sometimes  beneficial ;  however,  I  would  warn 
those  using  this  remedy  not  to  be  misled  by  the  tem- 
porary improvement,  for  frequently  cases  progress 
favourably  for  a  time,  only  to  relapse  when  the 
remedy  is  discontinued ;  and  I  have  known  a  habit  of 
taking  morphia  to  be  started  in  an  asylum. 

Passive  melaiicliolia.— Patients  in  this  class 
differ  greatly  from  the  last,  as  far  as  appearances  are 
concerned.  There  is  a  direct  series  leading  from 
simple  melancholy  through  passive  melancholia  into 
melancholy  with  stupor.  And  it  is  open  to  doubt 
whether  most  cases  described  as  acute  dementia  are 
not  rather  to  be  looked  upon  as  cases  belonging  to 
the  last  variety. 

Passive  melancholia  may  arise,  as  may  the  other 
varieties,  from  acute  or  chronic  causes.  It  may  occur 
in  men  or  women,  in  young  or  old.  But  again  I  would 
say,  the  majority  of  cases  seen  in  Bethlem  fall  between 
40  and  60.  The  incidence  is  generally  slow,  there 
being  a  gradual  failing  in  physical  health,  while  fre- 
quent complaints  of  dyspepsia  and  sleeplessness  are 
made.  Listlessness  and  an  aspect  of  anxiety,  restless 
worry,  or  jealousy,  are  often  the  first  objective  signs. 


Chap.  VII.]      Melancholia  with  Stupor.  179 

These  become  more  marked,  and  some  trivial  circum- 
stance establishes  the  fact  that  the  person  is  suffering 
from  delusions.  She  may  suddenly  accuse  her  hus- 
band of  wishing  to  poison  her,  or  reprove  him  for  not 
interfering  with  those  who  are  annoying  or  injuring 
her.  A  dream  of  horror  may  seem  to  precipitate  the 
illness ;  or,  what  is  a  common  experience  with  me  is, 
that  a  middle-aged  woman  nursing  a  relation  or 
friend  who  has  died,  becomes  haunted  by  the  idea 
that  she  has  caused  his  death.  Hallucinations, 
especially  of  hearing,  may  appear ;  she  hears  voices  of 
demons  tempting  to  evil,  jeers  of  spirits  or  of 
men  deriding  or  accusing  her  of  unworthiness.  The 
bodily  health  suffers  in  an  equal  degree  with  the 
mental ;  suicidal  tendencies  develop  themselves,  and 
not  unfrequently  desire  arises  to  kill  the  children,  if 
there  be  any,  to  save  them  from  further  chance  of 
misery.  A  more  pronounced  variety  of  the  same  con- 
dition is  met  with  in 

Melancholia  with  stupor.  —  In  this  the 
patients  are  speechless  and  passive,  but  with  an  aspect 
of  misery.  The  chief  point  is  the  more  or  less  com- 
plete loss  of  reaction  to  external  stimuli,  as  the  result 
of  oppression  from  dread  or  from  complete  subordi- 
nation of  all  intellectual  life  to  a  feeling  of  terror. 

I  believe  there  are  two  distinct  mental  conditions 
occurring  in  melancholia  with  stupor  ;  in  one  there 
is,  as  it  were,  prolonged  panic.  I  know  many 
persons  who,  under  suddenly  terrifying  circumstances, 
became  powerless  to  move  even  for  self-preservation, 
and  one  group  of  patients  suffering  from  melancholy 
with  stupor  seem  in  a  condition  very  similar  to  this. 

In  the  other  class  we  meet  with  patients  who  form 
a  very  definite  idea  of  an  impending  evil.  It  may 
vary  from  spiritual  destruction  to  bodily  annihilation  ; 
but  on  recovery  they  are  generally  able  to  tell 
what    was    the    mental  state    causing   their   physical 


i8o      Insanity  and  Allied  Neuroses.   [Chap.  vii. 

condition.  Patients  suffering  from  melancholia  with 
stupor  are  not  to  be  confounded  with  a  few  cases 
suffering  from  primary  dementia,  or  with  others  pos- 
sessed by  some  delusion  which  renders  them  statues- 
que. Some  writers  doubt  whether  such  a  condition  as 
acute  dementia  exists,  and  would  classify  all  cases 
of  this  kind  with  melancholy,  believing  that  every 
absolutely  passive  patient,  with  a  stolid  or  melancholic 
aspect,  is  suffering  from  some  delusive  horror.  I  can 
hardly  agree  with  this,  as  I  have  seen  at  least  one 
patient  who,  on  recovering,  said  that  the  time  of  his 
inactivity  was  really  a  blank  to  him,  and  was  in  no 
way  associated  with  painful  recollections.  I  would 
say  that  the  few  cases  of  acute  primary  dementia 
which  I  have  seen  have  followed  some  sudden 
fright,  injury,  or  poisoning  of  the  higher  nervous 
centres,  and  that  the  touchstone  is  that  of  memory ; 
that,  in  fact,  a  person  recovering  and  having  a  recol- 
lection of  misery  associated  with  his  illness  must  be 
looked  upon  as  suffering  from  melancholy  with  stupor, 
whereas  the  patient  suffering  from  acute  dementia 
would  have  no  such  recollections.  I  admit  that  a  few 
cases  of  very  acute  melancholia  deny  any  recollection 
of  their  state.  It  may  be  possible  that  certain  cases 
beginning  with  melancholy  and  having  painful  impres- 
sions may  pass  into  a  state  in  which  no  memory 
exists ;  that,  in  fact,  just  as  we  have  cases  of  acute 
mania  in  which  a  j)eriod  is  completely  forgotten,  so 
there  may  be  cases  of  melancholy  in  which  a  blank 
likewise  exists.  I  shall  take  it  for  granted  that  there 
is  a  distinction  between  the  conditions  called  dementia 
and  melancholia  with  stupor.  In  the  latter  there  may 
be  occasionally  ansesthesia,  but  I  have  not  found  this 
to  be  as  common  as  has  been  supposed.  Reaction 
may  be  slow,  but  patients  have  told  me  on  recovery 
that  they  felt  the  prick  which  I  had  given  them,  al- 
though they  did   not  flinch.     The  special  sensations 


Chap.  VII. J     Melancholia   with  Stupor.  i8[ 

are  confused  and  dull ;  people  about  the  patient 
often  appear  to  him  as  enemies,  either  as  his  execu- 
tioners or  as  people  sent  to  torture  or  remove  him  ; 
or  he  may  have   a  dream-like    idea    that  he   is  in  a 


A  case  of  Cataleptic  Melancholia. 

Strange  world  and  that  the  people  about  him  are  not 
inhabitants  of  the  earth  at  all.  One  of  the  charac- 
teristic symptoms  of  this  condition  is  muscular 
rigidity.  Patients  object  actively  to  everything  which 
is  done  for  them,  so  that  it  takes  two  or  three  persons 
to  dress  and  undress  them,  and  as  many  to  feed  them. 


1 82     Insanity  and  Allied  Neuroses.   [Chap.  vii. 

Be3'^ond  this  it  is  common  to  meet  with  catalepsy 
more  or  less  complete.  I.  have  rarely  met  with  this 
condition  in  a  very  fully  developed  form,  but  at  the 
same  time  it  is  rare  to  be  without  some  case  of  partial 
catalepsy  in  Bethlem. 

These  patients  invariably  have  other  accompanying 
physical  symptoms,  such  as  cold  livid  extremities,  ex- 
cessive flow  of  nasal  mucus,  and  general  disregard  of 
their  personal  appearance  ;  the  eyes  are  often  directed 
to  the  ground,  the  lids  being  half  closed,  with  a  honey- 
like excretion  exuding  along  the  edges ;  the  skin  is 
often  dewy  or  greasy  and  gives  a  feeling  of  coldness  to 
the  touch,  and  although  patients  with  stupor  do  not  take 
food  freely  or  voluntarily,  yet  if  they  are  kept  warm 
and  carefully  looked  after  they  do  not  emaciate.  Their 
temperature  is  readily  affected  by  their  surroundings. 
There  is  no  evidence  externally  of  intellectual  action, 
but  they  exhibit  will  in  so  far  as  they  resist  interference. 
This  condition  probably  is  best  represented  by  a  pro- 
found dream  or  nightmare.  The  result  of  such  cases 
is  not  favourable,  but  few  recovering.  This  con- 
dition occurs  more  frequently  in  the  young  than  in 
the  old,  and  is  certainly  as  common  in  young  men 
as  in  young  women.  Certain  cases  live  for  years 
in  much  the  same  condition,  having  to  be  washed, 
dressed,  fed,  and  tended  like  young  children,  while 
others  die  of  some  intercurrent  trouble,  most  frequently 
phthisis.  This  condition  may  follow  from  fright. 
Thus  I  have  known  a  young  sailor  whose  melancholic 
stupor  followed  shipwreck  and  fire,  both  occurring  on 
his  first  voyage.  In  another  case  a  false  accusation 
and  loss  of  situation  was  the  cause.  In  another  an 
attempted  rape  was  the  direct  origin  of  the  attack, 
and  a  fourth  followed  brutality  or  excess  on  the  part 
of  a  husband  on  the  marriage  night. 

To  conclude,  following  the  example  of  Professor 
Griesinger,    I   have   arranged   the   symptoms    which 


Chap.  VII.]     Melancholia  with  Stupor.  183 

distinguish  between  raelancliolia  with,  stupor  and.  de- 
mentia in  the  following  tabular  form  : 

MELANCHOLIA  WITH  STUPOR.  DEMENTIA. 

Development,  often  rapid.  Slow. 

Nutrition  fails.  Often  good. 

Complexion,  yellow.  Normal. 

Excretions,  deficient.  NormaL 

Sleep,  bad.  Good. 

Opposition  to  ail  movements  Passive. 

Appetite,  refusal  of  food.  Voracious. 

Suicidal.  Not  suicidal. 

Memory,  present.  Absent. 

Having  ah-eady  considered  simple  melancholia, 
active  and  passive  melancholia,  and  melancholia  with 
stupor,  I  shall  proceed  to  notice  first  the  relationships 
of  melancholy  to  delusions,  hallucinations,  and  other 
sense-perversions ;  secondly,  cases  specially  suicidal ; 
thirdly,  those  which  have  been  called  religious 
melancholies  ;  fourthly,  melancholia  as  connected  with 
certain  periods  of  life,  such  as  the  climacteric  and 
senility ;  fifthly,  the  same  condition  as  related  to 
certain  bodily  disorders,  such  as  gout,  heart  disease, 
and  kidney  disease ;  finishing  with  a  consideration  of 
recurring  and  chronic  cases  in  which  recovery  has 
been  long  retarded. 

The  feeling  of  mental  depression  is  like  a  cloud 
'twixt  sun  and  earth ;  it  slowly  settles  upon  a  mind, 
gradually  blotting  out  the  light  of  hope  and  desire, 
and  leaves  it  ready  to  pass  under  any  depressing  in- 
fluence. There  has  been  seen  to  be  a  dulling  of  the 
whole  life,  and  this  becomes  more  and  more  pro- 
nounced till  every  part  of  the  being  reacts  slowly  and 
painfully.  This,  in  its  earliest  state,  is  that  of  simple 
melancholia,  which  I  have  already  described  ;  but  a 
further  stage  may  be  developed,  so  that  a  patient, 
feeling  wretched  and  utterly  unlike  himself,  seeks 
for  some  explanation  of  the  state.  It  has  been 
said  tliat  wise  men  investigate  while   fools  explain ; 


184     Insanity  and  Allied  Neuroses,   [chap.  vii. 

and  I  am  sure  that  none  are  so  ready  to  explain  as  tlie 
insane. 

The  explanation  of  his  miseries  given  by  the 
patient  suffering  from  melancholia  depends  to  a  great 
extent  upon  his  inheritance,  his  education,  and  his 
surroundings  at  the  time  of  his  illness.  The  expla- 
nation may  be  a  direct  development,  as  seen  in  the 
emotional  girl  who  has  been  brought  up  in  the  midst 
of  enthusiastic  dissenters,  who  thinks  her  state  is  pro- 
duced by  the  neglect  of  religious  ordinances  of  which 
she  has  heard  so  much  ;  or  the  explanation  may  be 
in  direct  antagonism  to  the  past  life ;  thus,  the 
man  who  has  lived  a  worldly,  careless  life^  when  he 
is  melancholic,  turns  to  religion  for  an  explanation. 
The  anxious  mother  may  explain  her  misery  by 
imagining  that  her  children  are  suffering  or  are  in 
danger,  while  the  merchant  dreads  insolvency,  and  the 
old  man  fears  loss  of  reputation  and  the  workhouse. 

The  following  is  a  good  example  of  the  way  in 
which  delusions  of  this  kind  arise :  A  farmer  in 
England  finds  the  times  a2:ainst  him.  He  has  a 
large  and  increasing  family  with  yearly  reduction  of 
capital.  Hather  than  lose  everything,  he  determines 
to  realise  the  property  still  remaining  to  him,  and 
try  his  fortune  in  another  land.  He  sells  his  stock, 
and  leaving  his  wife  (who  is  six  months  pregnant) 
with  her  family  in  England,  he  proceeds  to  New 
Zealand.  The  money  he  left  for  his  wife  was  suffi- 
cient to  last  a  year  or  so,  but  the  anxious  pregnant 
woman,  fearing  something  might  happen  to  him  or  his 
funds,  saves  and  pinches,  not  supplying  herself  with 
food  necessary  for  her  condition.  She  works  constantly 
for  her  children,  even  up  to  the  time  of  her  delivery, 
and  refusing  extra  diet,  she  leaves  her  bed  to  resume 
her  domestic  duties  far  too  soon.  Here,  then,  we 
have  physical  causes  of  weakness  associated  with  con- 
stant mental  anxiety,  and  as  a  result,  depression  and 


chnp.  VII,  A UTOBioGRAriiv  OF  A  Melancholic.     185 

sleeplessness,  the  two  becoming  more  pronounced, 
till  at  last  she  refuses  food,  ha\dng  the  conviction  that 
there  is  no  more  food  in  the  vv^hole  world,  and  that 
everything  she  eats  is  reducing  the  small  stock  that 
is  to  maintain  humanity.  Similar  growths  of  delu- 
sions may  constantly  be  witnessed. 

As  another  example  I  would  refer  to  a  man 
who,  being  entitled  to  a  sum  of  money,  which  he 
accepts  instead  of  a  pension,  started  a  business  for 
his  only  son.  He  had  no  sooner  done  this  than  he 
was  impressed  with  the  risk  he  now  ran  of  dying 
in  poverty,  there  being  no  longer  a  certainty  of 
an  income  when  he  was  beyond  work.  Slowly  but 
surely  the  misery  wrought  upon  him,  till,  passing 
through  the  vague  period  of  unexplained  wretched- 
ness, he  became  possessed  with  the  idea  that  he  was 
ruined,  friendless,  and  a  beggar,  and  must  be  thrust 
out  into  the  streets. 

Autolbiograpbical  sketch  of  melancliolia, 
and  recovery. — "  I  am  thirty-two  years  of  age,  and 
have  been  married  ten  years.  I  was  fore-woman  in  a 
silk  warehouse  in  the  city.  While  there  I  suffered 
from  pleurisy  in  the  side,  which  was  thought  to  be 
caused  by  carrying  heavy  things.  I  also  suffered 
from  headache  during  the  whole  ten  years  I  was  so 
employed.  My  employers  failed  in  business,  and 
soon  after  I  got  married.  I  was  of  very  active  habits 
and  excitable  temperament.  After  marriage  I  missed 
the  active  life  I  was  accustomed  to  in  the  city,  and 
became  somewhat  melancholy,  and  suffered  slightly 
from  headache.  I  had  four  children  within  four  and 
a  half  years,  and  then  six  years  elapsed  without  any 
addition  to  my  family.  I  then  had  another  child,  whom 
I  lost  when  he  was  six  years  old.  Shortly  before  his 
death,  my  neighbour  induced  my  landlord  to  give  my 
husband  notice  to  quit,  but  this  notice  was  not  carried 
out.     I  was  always  at  home  all  day  alone,  my  husband 


1 86     Insanity  and  Allied  Neuroses.  [Chap.  vii. 

following  his  occupation.  This  notice  to  quit  gave 
me  a  shock,  and  the  death  of  my  child,  soon 
afterwards  following,  intensified  it.  During  my 
previous  confinements,  I  had  had  upsets,  particularly 
in  the  second  one.  I  then  saw  the  antimacassar 
around  the  looking-glass  in  my  bedroom  on  fire.  I 
screamed,  and  was  queer  from  that  time,  but  re- 
covered, and  had  another  child.  This,  the  last 
confinement,  was  a  very  bad  one,  the  baby  being  very 
large.  I  now  became  exceedingly  nervous,  and 
dreaded  some  one  was  coming  to  arrest  me  for  a 
murder  I  had  committed.  This  delusion  continued 
about  three  months,  and  my  child  had  to  be  fed  by 
bottle,  my  milk  having  stopped.  I  did  not  believe 
my  child  was  dead.  I  always  had  the  sensation  of 
falling  into  a  deep  black  place.  This  lasted  night  and 
day  for  three  weeks,  the  death  of  my  child  having  so 
much  afl[ected  me.  I  underwent  medical  treatment 
at  my  home,  but  derived  no  benefit  therefrom.  I  was 
then  brought  to  Bethlem  in  May,  1883,  having  the 
idea  that  I  was  being  taken  to  a  museum.  As  soon 
as  I  entered  Bethlem  (not  knowing  it  was  an  asylum), 
I  screamed,  thinking  that  steam  was  coming  from  a 
boiler.  I  was  taken  to  a  padded  room,  and  soon 
after  the  paroxysm  left  me  I  felt  relieved.  I  laboured 
under  the  idea  that  all  who  were  in  the  asylum  were 
transformed  into  dogs,  and  the  feeling  I  experieiiced 
was  like  sulphur  rising  in  me.  My  food  tasted  as 
bitter  as  wormwood.  Those  particular  delusions 
lasted  about  two  months.  I  used  to  watch  the 
patients  all  night,  thinking  they  were  goiug  to  fly 
on  me  and  devour  me.  In  tliis  way  I  was  without 
sleep  for  nearly  two  months,  restless,  got  out  of  bed, 
and  walked  about.  The  delusion  then  took  another 
turn  in  the  shape  of  my  imagining  that  the  woman 
who  induced  my  landlord  to  give  me  notice  to  quit 
was  in  collusion  with  God,  and  that  I  was  God ;  and 


Chap.  VII.]      Autobiographical  Sketch.  187 

every  time  I  went  to  see  her  she  hid  behind  the 
garden.  I  thought  all  the  people  in  the  asylum  were 
there  for  twelve  months  playing  their  part  until  the 
judgment  day,  when  they  would  be  saved  from  their 
sins.  I  also  thought  that  all  the  world  was  a  delusion. 
The  night  I  was  put  into  the  padded  room  I  kept 
running  about,  thinking  that  the  padding  was  going 
to  give  way.  I  also  imagmed  that  all  the  food  was 
poison,  so  refused  to  take  it.  The  day  I  looked  at 
my  tongue  and  eyes,  I  said  that  they  were  to  be  taken 
out ;  I  thought  God  had  ordained  it.  I  was  always 
groaning  and  crying,  alleging  it  was  my  fate  to  go 
through  these  dreadful  things,  and  that  the  day  would 
arrive  when  I  should  be  crucified,  and  that  when  I 
went  to  bed  I  should  be  summoned  during  the  night 
to  go  through  it.  I  also  had  a  delusion  that  my 
husband  and  my  family  were  in  Bethlem,  and  that  I 
was  Christ.  I  never  told  my  delusions  to  any  one, 
until  after  being  in  Bethlem  two  months,  when  I 
mentioned  them  to  a  patient  who  slept  in  the  same 
room  with  me.  On  that  occasion  I  asked  her  if  I  was 
Christ,  and  the  patient  replied,  '  No  !  Do  you  think 
a  poor  woman  like  you  is  Christ  % '  I  have  lost  my 
delusions,  and  was  sent  to  Witley  about  six  weeks 
ago,  and  have  returned  recovered.  I  now  sleep  well 
throughout  the  night,  sometimes  dreaming  of  my 
child.  I  enjoy  my  dinner  and  supper,  but  cannot  eat 
in  the  morning.  I  am  not  the  same  person  since  I 
had  the  cholera  when  I  was  fifteen  years  old. 
At  first,  when  friends  came  to  see  me  in  Bethlem  I 
used  to  cry  and  did  not  care  to  see  them,  as  I 
imagined  they  were  not  my  own  friends ;  but  now  I 
receive  their  visits  with  extreme  pleasure,  and  feel 
sorry  when  they  are  going  away,  and  their  departure 
does  not  affect  me  afterwards.  My  mother's  brother 
died  at  Hanwell ;  my  sister  died  at  the  White  House, 
Bethnal  Green  (this  sister  having  had  a  fright  when 


1 88     Insanity  and  Allied  Neuroses.    [Chap.  vii. 

a  child),  and  another  sister  was  also  there  soon  after 
lier  confinement.  I  have  a  cousin  (mj  father's 
brother's  son)  now  in  Colney  Hatch.  All  my  sisters 
and  my  mother  suffered  from  headache.  I  was  not 
afraid  of  any  of  them,  and  would  do  anything  to  help 
them.      I  was  discharged  recovered." 

These  examples  show  what  I  mean  when  I  say 
that  (as  chemists  might  put  it),  there  being  a  saturated 
solution  of  misery,  a  crystal  forms  with  a  definite  out- 
line. In  a  few  cases  undoubtedly  the  melancholy 
follows  some  delusion,  but  as  a  rule  the  delusion  has 
been  started  by  some  slowly  developed  morbid  process. 
It  is  natural  that  a  man  should  be  melancholic  who 
believes  that  he  has  lost  his  inside,  or  that  there  are 
wild  beasts  within  him  ;  and  the  woman  who  believes 
that  she  is  nightly  injured,  threatened,  or  assaulted, 
becomes  miserable  and  depressed.  Thus,  a  woman  in 
Bethlem,  who  believed  that  evil  spirits  came  to  her 
room  and  abused  her  sexually,  became  desperately 
suicidal.  The  delusions  were  marked  before  the  other 
melancholic  symptoms  exhibited  themselves  ;  but  in 
tracing  back  we  find  the  delusions  had  their  origin  in 
some  hallucination  of  the  senses. 

Suicide  has  been  referred  to  when  considering 
the  general  symptoms  of  melancholia :  and  although 
1  object  to  classify  cases  purely  from  the  existence  of 
one  symptom,  yet,  when  we  remember  the  great  social 
and  general  importance  attached  to  suicide,  I  think  it 
deserves  consideration  rather  more  in  detail  than 
many  other  special  symptoms.  We  have  seen  that 
ideas  of  self-destruction  may  arise  from  various  feel- 
ings bodily  and  mental,  and  I  know  no  special  class 
characteristics  which  would  enable  me  to  say  there  is 
a  special  suicidal  insanity.  Suicide  is  met  with  more 
frequently  at  an  earlier  age  among  members  of  the 
more  emotional  races  than  with  us  in  England, 
and    it    is   not   uncommon  in  France  and  Italy   for 


Chap.  VII.]  Suicidal   Tendencies.  189 

sentimental  children  to  drown  themselves  because 
of  a  rebuke  or  the  loss  of  a  pet,  or  in  consequence  of 
some  trivial  neglect  or  supposed  insult.  Occasionally 
in  England  schoolboys  will  kill  themselves  from  some 
slight  disturbing  cause.  As  age  increases  the  tendency 
to  commit  suicide  increases  also,  and  it  will  be  seen 
from  statistics  that  there  is  scarcely  any  limit  to  the 
age  at  which  men  may  get  tired  of  life.  Men  and 
women  both  commit  suicide,  but  there  are  certain 
favourite  methods  which  each  sex  prefers.  A  man 
will  cut  his  throat  or  blow  his  brains  out,  while  a 
woman  will  hang  or  drown  herself.  It  has  even  been 
shown  that  seasons  of  the  year  affect  the  mode  and 
number  of  suicides.  I  may  say  that;  for  my  part,  I 
find  it  hard  to  agree  with  the  verdict  of  English 
society,  that  every  person  who  takes  his  life  is  neces- 
sarily a  lunatic.  That  a  man  in  killing  himself  is 
generally  doing  an  unreasonable  act  I  admit,  but  that 
this  act  connotes  a  general  intellectual  disturbance, 
which  can  be  fairly  grouped  under  any  pathological 
heading,  I  doubt.  To  act  on  impulse  is  unreasonable, 
but  many  of  our  best,  as  well  as  some  of  our  worst, 
actions  follow  impulse^  and  suicide  too  may  result  from 
impulse.  Suicide  may  be  carefully  thought  out ;  thus 
I  have  seen  one  patient  at  least,  who,  having  most 
carefully  considered  whether  his  children  would  be 
pecuniarily  benefited  if  he  died,  finding  that  they  would 
certainly  be  better  off  by  his  death  than  by  his  life,  took 
the  most  cool  and  deliberate  means  to  effect  his  end. 
As  it  turned  out,  although  he  ought  to  have  died  from 
his  wounds,  he  did  not,  and  although  carefully  made, 
he  had  miscalculated  his  pecuniary  relationships. 

There  are  cases  in  every  asylum  for  which  special 
provision  is  required,  and  it  will  be  well  to  give 
examples.  Such  cases  are  generally  of  insane  inheri- 
tance. Frequently  suicidal  tendencies  have  been  trans- 
mitted from  father  to  son  ;  and,  as  in  the  causation 


190      Insanity  and  Allied  Neuroses.  [Chap.  vii. 

of  insanity  I  referred  to  direct  inheritance,  and  gave 
as  an  example  the  suicidal  tendency,  I  would  repeat 
that  nothing  has  struck  me  more  than  the  histories 
I  have  received  of  direct  suicidal  inheritance. 

The  most  suicidal  patients,  in  my  experience,  are 
those  who  believe  that  they  are  to  be  injured. 
Suicidal  tendencies  are  most  marked  in  the  early 
morning.  There  seems  to  be  a  feeling  of  horror  which 
drives  them  to  distraction,  and  makes  them  prefer 
suicide  to  persecution.  In  one  young  woman  in 
Bethlem  the  tendency  to  suicide  was  extreme,  and 
being  prevented  in  every  ordinary  way  from  injuring 
herself,  she  tried  to  destroy  her  life  by  swallowing 
broken  china,  buttons,  corks,  horse-hair,  and  every 
available  irritating  substance  she  could  get  her  mouth 
to.  These  insane  acts  proved  the  means  of  her 
recovery,  for  the  collection  of  foreign  bodies  in  her 
stomach  set  up  such  violent  pain  and  colic  that  they 
were  only  relieved  by  a  large  dose  of  calomel,  which 
brought  away  the  irritating  matters  and  left  her  free 
from  pain  and  delusions. 

Another  good  example  of  an  extremely  suicidal 
patient  is  that  of  a  man  admitted  into  Bethlem  in  the 
early  part  of  1883.  His  insanity  was  strongly  marked 
on  the  mother's  side.  He  had  received  two  or  three 
severe  injuries  in  railway  accidents  during  his  life,  and 
was  lame.  He  was  employed  as  signalman  in  a  very 
quiet  place,  where  the  number  of  hours  he  was  on 
duty  debarred  him  from  having  much  companionship, 
most  of  his  time  being  spent  in  waiting  and  watching 
Naturally  a  man  of  nervous  disposition  by  inheritance, 
and  rendered  more  unstable  by  physical  weakness  and 
maiming,  he  dwelt  upon  his  misfortunes,  which  in- 
creased in  magnitude  as  he  contemplated  them.  The 
morbid  mental  growth  developed,  and  he  became  im- 
pressed with  the  idea  that  his  wife  and  children  were 
l3eing  injured.     He  had  hallucinations  of  hearing,  and 


Chap.  VII.]  Suicidal  Tendencies.  iqi 

was  constantly  horrified  by  the  voice  of  his  wife  and 
children,  who  were  being,  as  he  thought,  tortured. 
In  this  condition  he  was  brought  to  Bethlem, 
and  for  some  two  or  three  weeks  he  caused  great 
anxiety.  His  general  health  was  attended  to,  and  he 
was  encouraged  to  do  little  jobs  about  the  ward.  His 
interest  was  aroused,  his  wife  and  children  were  allowed 
to  see  him  and  write  to  him  frequently,  and  with  the 
bodily  improvement  confidence  became  re-established, 
and  after  a  few  weeks'  residence  at  the  convalescent 
home  he  was  discharged  well,  having  been  under  treat- 
ment only  some  seven  weeks. 

In  another  case,  a  single  man  thirty  years  old,  a 
decorator  and  grainer,  without  any  known  insane 
inheritance,  began  to  fail  in  general  health  some  two 
or  three  years  before  he  was  admitted  into  Bethlem. 
He  had  haemoptysis  with  cough  and  loss  of  flesh,  but 
there  were  no  evident  signs  of  phthisis.  He  became 
despondent  about  his  condition,  was  restless,  and 
made  several  attempts  at  self-destruction.  He  grew 
weaker  and  more  nervous,  was  haunted  by  voices 
talking  at  him,  and  annoyed  by  unpleasant  smells,  in 
consequence  of  which  he  refused  animal  food.  He 
took  a  great  dislike  to  all  his  relatives,  thinking 
they  were  in  league  against  him.  On  admission 
he  was  a  thin,  anxious,  worried-looking  man,  suffering 
still  from  an  injury  produced  by  his  having  thrown 
himself  under  a  railway  train.  While  in  the  hospital 
he  varied  considerably,  at  one  time  rapidly  losing 
flesh,  and  bringing  up  considerable  quantities  of  blood, 
at  which  times  he  generally  was  more  amenable  to 
treatment  and  discipline.  When  these  attacks  passed 
off,  and  he  again  recovered  his  general  health,  his 
mind  became  distressed,  and  he  was  once  more 
troubled  by  hallucinations,  in  consequence  of  which 
he  refused  his  food.  He  had  to  be  fed  constantly  by 
the    stomach-pump,   but  after   several   remissions   he 


192     Insanity  and  Allied  Neuroses.   [Chap.  vii. 

steadily  began  to  improve  both  in  body  and  in  mind, 
and  at  length  became  sane  and  in  fair  bodily  condition. 
His  case  is  an  example  of  suicidal  tendencies  de- 
pending upon  physical  weakness  and  bodily  disease, 
which  being  removed,  allow  the  disappearance  of 
suicidal  tendency. 

In  the  next  case  the  suicidal  tendency,  which  was 
the  most  troublesome  symptom,  has  not  disappeared, 
although  the  patient  has  suffered  for  over  three 
years.  He  was  a  banker's  clerk,  married,  and  of 
steady  habits.  His  mother  and  sister  have  both  been 
insane,  but  have  recovered,  and  two  of  his  maternal 
uncles  committed  suicide.  He  was  a  German  who 
had  come  to  England  to  push  his  way,  and  by  despe- 
rate energy  and  hard  work  had  risen  to  a  position  of 
considerable  trust  and  importance  in  a  foreign  bank- 
ing-house. He  had  always  been  an  exacting,  self- 
conscious  man,  and  in  consequence  of  financial  troubles 
in  the  city  he  became  sleepless  and  irritable.  He 
believed  that  the  head  of  the  firm  was  anxious  to  dis- 
place him,  and  that  there  w^as  a  conspiracy  in  the 
ofiice  to  accuse  him  of  theft.  He  had  also  hallucina- 
tions of  smell,  was  suspicious  about  his  wife,  and 
being  a  fond  father,  he  thought  the  interests  of  his 
children  were  being  neglected.  Before  admission  he 
cut  his  throat  seriously,  nearly  killing  himself. 
With  difficulty  his  life  was  saved,  but  he  was  in 
no  way  to  be  trusted,  being  a  source  of  constant 
anxiety  and  trouble.  At  the  same  time  he  was  over- 
sensitive, and  full  of  the  belief  that  other  patients 
wished  to  annoy  him.  Thus  in  a  letter  to  me  he 
says  :  "  When  in  the  lavatory,  one  of  those  present, 
placing  himself  in  an  unmistakable,  loathsome  atti- 
tude, asked  me  if  I  had  had  a  good  night,  a  hint 
being  conveyed  to  him  by  one  of  the  persons  sleep- 
ing in  the  same  room  in  which  I  sleep.  I  mentioned 
it  to  you  a  long  time  ago,  and  the   tricks  and  foul 


Chap.  VII.]  Suicidal  Tendencies.  193 

insinuations  have  been  of  constant  occurrence."  This 
patient  did  not  recover,  and  the  prospect  is  highly- 
unfavourable.  In  connection  with  this  case  it  is 
well  to  mention  the  fact  that  patients  who  are  an- 
noyed by  hallucinations  also  suffer  from  what  they 
call  "  these  hints,"  and  are  both  dangerous  to  them- 
selves and  to  others. 

I  shall,  under  the  head  of  delusional  insanity, 
give  the  case  of  one  who  has  threatened  violence 
to  others,  and  who  says  that  although  he  considers 
suicide  a  sign  of  weakness,  yet  he  fully  recognises 
the  fact  that  annoyances  may  be  carried  to  such  an 
extent  that  it  would  be  better  for  him  to  die  than  to 
endure,  and  I  fear  that  if  he  deliberately  made  up 
his  mind  on  this  matter,  it  would  be  impossible  to 
j)revent  him  accomplishing  his  end. 

Intensely  suicidal  ideas  arise,  not  only,  then, 
from  pure  misery  and  from  dread  of  persecution,  or 
in  consequence  of  annoyances  arising  from  bodily  and 
mental  nervous  disturbance,  but  danger  also  occurs  in 
the  stage  of  depression  following  excitement.  In  this 
way  I  have  seen  one  woman  destroy  herself  just 
as  she  was  beginning  to  improve.  She  had,  as  it 
were,  opened  her  eyes  to  the  fact  that  she  was  in  an 
asylum,  and  it  seemed  such  a  terrible  thing  to  con- 
template that  she  strangled  herself.  Although  it 
is  generally  somewhat  easy  to  recognise  suicidal  ten- 
dencies in  patients,  he  would  be  rash  who  would  say 
that  a  person  of  unsound  mind,  of  whatever  the 
variety,  would  not  attempt  self-destruction.  Young 
emotional  patients  frequently  threaten  and  appear 
determined  on  suicide,  but  they  rarely  carry  their 
threats  into  execution.  General  paralytics  very 
rarely,  if  ever,  intentionally  kill  themselves ;  though 
their  exaggerated  ideas,  and  their  loss  of  common  sen- 
sibility may  lead  them  into  accidents  which  may  end 
fatally.  The  acutely  maniacal  patient  injures  himself 
N — 14 


194       Insanity  and  Allied  Neuroses,  [chap.  vii. 

under  similar  circumstances,  and  the  weak-minded 
patient  may,  by  accident,  get  into  mischief;  but 
suicide  must  ever  be  looked  upon  as  one  of  the  dan- 
gerous symptoms  connected  chiefly  with  melancholia. 

The  so-called  religious  insanity  has  been  referred 
to  when  considering  the  influence  of  religious  teaching 
upon  the  production  of  insanity;  and  also  when 
tracing  the  origin  of  delusions  and  their  explana- 
tion. It  is  only  just  to  own  that  although  there 
can  never  be  a  clinical  group  of  cases  with  reli- 
gious ideas  as  the  distinguishing  characteristic,  yet 
in  asylums  we  ever  meet  with  cases  aptly  called 
"the  unpardonable  sinners."  These  patients,  for  the 
most  part,  have  been  brought  up  in  narrow  religious 
sects,  and  many  of  them  have  been  agents  in  one  way 
or  another  for  the  dissemination  of  religious  know- 
ledge. Among  men  with  these  ideas  we  constantly 
meet  with  the  Sunday-school  teacher,  the  Scripture 
reader,  and  city  missionary,  and  among  women 
those  similarly  engaged.  We  may  meet  with  these 
cases  in  very  young  girls  and  boys,  who  by  the 
type  of  their  symptoms  prove  the  close  connection 
existing  between  the  erotic  and  religious.  This 
class  is  not  so  well  represented  in  full  manhood  and 
womanhood,  unless  some  special  causes  of  exhaustion 
have  arisen.  At  the  climacteric  they  are  specially 
common,  and  in  Bethlem  we  are  rarely  without 
many  women  whose  whole  ideas  of  life  are  cramped 
by  the  belief  that  they  are  unpardonable  sinners. 

I  am  frequently  asked  what  is  the  unpardonable 
sin,  and  what  does  the  patient  mean  by  this  sin.  In 
many  cases  it  refers  to  some  sexual  abuse.  In  the 
younger  patients  the  idea  has  often  arisen  from  indul- 
gence in  masturbation  during  the  time  they  were 
professing  Christians.  In  many  patients,  at  the 
climacteric,  some  sexual  disorder  again  has  tinged 
or  started  the  delusion.     In  a  few  cases,  before  the 


Chap.  VII.]  The   Unpardonable  Sin.  195 

mental  depression  there  was  a  stage  of  excitement, 
connected  with  the  increased  erotic  tendencies,  at 
which  time  the  patient  indulged  in  sexual  excess  or 
masturbation,  and  when  the  period  of  depression  fol- 
lowed he  came  to  consider  this  unnatural  offence 
in  a  person  of  mature  years  to  be  the  unpardonable 
sin.  The  most  common  idea  and  the  scriptural  one 
is  that  the  unpardonable  sin  is  blasphemy  against  the 
Holy  Ghost  (St.  Matthew  xii.  31)  ;  but  here  arises 
the  difficulty  as  to  what  blasphemy  against  the  Holy 
Ghost  is.  I  have  known  a  lad  suffering  from  melan- 
cholia, who  believed  that  he  committed  that  sin  when 
he  thrust  his  penknife  into  the  ground  and  combined 
the  name  of  the  Holy  Ghost  with  an  ordinary  curse. 

Perhaps  in  no  published  work  is  the  sad  tale  of 
the  fall  of  a  high-sou  led,  pure-hearted  man,  reared  in 
the  bosom  of  religion,  into  this  terrible  state,  told  more 
graphically  or  with  more  intensity  than  in  George 
Borrow's  strange  but  pleasant  book,  "  Lavengro." 
Peter,  the  hero  of  the  work,  thus  describes  his  temp- 
tation, his  fall,  his  emotions,  his  remorse,  his  despair, 
and  finally  his  resurrection  from  the  depths  into  which 
he  had  fallen. 

"  One  autumn  afternoon,  on  a  week-day,  my  father 
sat  with  one  of  his  neighbours  taking  a  cup  of  ale  by 
the  oak  table  in  our  stone  kitchen.  I  sat  near  them 
and  listened  to  their  discourse.  They  were  talking  of 
religious  matters.  'It  is  a  hard  matter  to  get  to 
heaven,'  said  my  father.  '  Exceedingly  so,'  said  the 
other.  '  However,  I  don't  despond ;  none  need  de- 
spair of  getting  to  heaven  save  those  who  have  com- 
mitted the  sin  against  the  Holy  Ghost.^  'Ah,'  said 
my  father,  '  thank  God  I  have  never  committed  that ! 
how  awful  must  be  the  state  of  the  person  who  has 
committed  the  sin  against  the  Holy  Ghost  I  I  can 
scarcely  think  of  it  without  my  hair  standing  on  end.' 

"And  then  my  father  and  his  friend  began  talking 


196       Insanity  and  Allied  Neuroses.  [Chap.  vii. 

of  the  nature  of  the  sin  against  the  Holy  Ghost,  and 
I  heard  them  say  what  it  was.  as  I  sat  with  greedy 
ears  listening  to  their  discourse."  The  evil  seed  had 
been  sown.  Truly,  "  ignorance  is  bliss,"  where  it  is 
not  merely  folly,  but  criminal,  to  be  wise.  Peter  con- 
tinues his  pathetic  tale.  After  describing  his  tempta- 
tions, his  broodings,  and  his  surmises  as  to  what  must 
be  the  condition  of  the  person  who  had  committed  the 
sin  against  the  Holy  Ghost,  his  strong  inclinations  to 
commit  it  himself,  were  it  not  that  a  strange  kind  of 
fear  "prevented  me";  his  decisive  declaration  that 
from  his  experience  "it  is  not  a  good  thing  for  chil- 
dren to  sleep  alone " ;  his  inattention  at  school  ;  he 
thus  finally  describes  his  fall  after  fearful  struggles : 

"  Arising  from  my  bed,  I  went  upon  the  wooden 
gallery,  and  having  stood  for  a  few  minutes  looking  at 
the  stars  with  which  the  heavens  were  thickly  strewn, 
I  laid  myself  down,  and,  supporting  my  face  with  my 
hands,  I  murmured  out  words  of  horror,  words  not  to 
be  repeated,  and  in  this  manner  I  committed  the  sin 
against  the  Holy  Ghost."  Angels  might  have  wept 
over  the  fall  of  poor  Peter  Williams,  for  he  knew  not 
what  he  did. 

His  description  of  his  after-state  of  remorse  and 
despair  is  a  most  strikingly  graphic  piece  of  descrip- 
tive writing.  How  it  must  come  home  to  the  soul- 
rending  experience  of  hundreds  of  thousands  of 
young  people  to-day,  who  have  been  moved  by  emo- 
tional teachers  !  He  felt  stupefied ;  he  had  a  dim 
idea  that  something  strange  and  monstrous  had  oc- 
curred j  at  school  he  could  not  learn ;  cheerfulness 
abandoned  him  ;  he  became  reserved  and  gloomy. 
"I  seemed,"  he  says,  "in  my  own  eyes  a  lone  mon- 
strous being ;"  and  he  could  not  pray.  "What  is  the 
use  of  praying"?"  he  said;  "I  have  committed  the  sin 
against  the  Holy  Gliost." 

He  describes  the  death-bed  scene  of  his  father,  and 


Chap.  VII.]      Story  of  Peter    Williams.  197 

how  his  beloved  parent's  parting  words,  "  trusting  they 
would  meet  in  heaven,"  filled  him  with  horror.  He 
progressed  in  years,  and  worked  hard  for  his  intellec- 
tual improvement,  yet  physically  and  mentally  he  was 
still  deeply  affected.  He  would  sit  brooding  alone, 
and  "  count  the  months  and  the  days  which  yet  inter- 
vened between  me  and  my  doom,"  for  he  felt  his  days 
were  being  shortened.  At  last,  after  terrific  struggles, 
lie  abandoned  home  and  family,  and,  "  a  prey  to 
horror  and  despair,"  ran  wild  through  the  hills  of  his 
native  Wales.  He  fell  into  the  hands  of  robbers  and 
gipsies  j  he  was  burnt  by  the  sun,  and  drenched  by 
the  rain,  and  "  had  frequently  at  night  no  other 
covering  than  the  sky  or  the  roof  of  some  cave." 
At  last  his  desperation  culminated  in  the  awful 
temptation  to  self-destruction,  from  which  crime  he 
was  saved  by  what  he  considered  to  be  a  merciful 
interposition  of  Providence. 

"  I  felt  myself  quite  unable  to  bear  the  horrors  of 
my  situation ;  looking  around,  I  found  myself  near 
the  sea ;  instantly  the  idea  caine  into  my  head  that  I 
would  cast  myself  into  it,  and  thus  anticipate  my  final 
doom.  I  hesitated  a  moment,  but  a  voice  within  me 
seemed  to  tell  me  I  could  do  no  better ;  the  sea  was 
near  and  I  could  not  swim,  so  I  determined  to  fling 
myself  into  the  sea," 

Then  he  gives  the  following  account  of  his  won- 
derful escape. 

"  As  I  was  running  along  with  great  speed  in  the 
direction  of  a  lofty  rock  which  butted  over  the  waters, 
I  suddenly  felt  myself  seized  by  the  coat ;  I  strove  to 
tear  myself  away ;  looking  around,  I  beheld  a  vener- 
able, hale  old  man,  who  had  hold  of  me.  '  Let  me  go,' 
said  I  fiercely.  '  I  shall  not  let  thee  go,'  said  the  old 
man  !  '  In  whose  name  dost  thou  detain  me  % '  said  I, 
scarcely  knowing  what  I  said.  '  In  the  name  of  my 
Master,  who  made  thee  and  yonder  sea,  and  has  said 


198  IXSANITV  AND    AlLIED    NeUROSES.  [Chap.  VII. 

to  the  sea,  So  far  shall  thou  come,  and  no  farther  ;  and 
to  thee,  Thou  shalt  do  no  murder  I ' "  The  old  man, 
knowing  Peter's  mother,  from  whom  he  had  received 
much  kindness  when  on  a  journey,  conducted  him  to 
his  house,  and  although  Peter  did  not  unbosom  him- 
self, he  confessed  he  was  sorely  afflicted  in  mind.  The 
old  man  knelt  down  and  prayed  long  and  fervently, 
Peter  kneeling  likewise.  When  they  had  risen  from 
their  knees  the  old  man  left  him  for  a  short  time,  and 
on  liis  return  led  him  into  another  room,  where  there 
were  two  females  ;  one  was  an  elderly  person,  the  old 
man's  wife,  the  other  was  a  young  woman,  who  was 
a  distant  relation  to  the  old  man.  He  remained 
several  davs  in  the  old  man's  house,  and  after  receiving 
repeated  words  of  consolation  and  encouragement,  de- 
parted for  his  home.  Peter  arrived  safely,  to  find  that 
his  cousin  had  died  and  left  him  his  heir,  and  that  the 
goodly  farm  on  which  his  cousin  had  lived  was  now  his 
property,  and  in  a  few  days  he  took  possession  of 
it.  Here  he  felt  his  solitude,  and  frequently  wished 
for  a  companion  with  whom  he  could  exchange  ideas, 
and  who  could  take  an  interest  in  his  pursuits. 
He  remembered  that  the  Scripture  says  that  it  is  not 
good  for  man  to  be  alone,  and  then  it  was  that  the 
image  of  the  young  person  (Winifred)  whom  he  had 
seen  in  the  house  of  the  old  man  frequently  rose  up 
distinctly  before  his  mind's  eye.  He  resolved  to  make 
suit,  was  successful,  and  soon  won  her  heart.  He 
married  her.  His  affairs  prospered,  so  that  he  was 
almost  happy,  taking  pleasure  in  everything  around 
him,  in  his  wife,  his  farm,  his  books  and  composition, 
and  the  Welsh  language,  till  one  night,  as  he  was  read- 
ing the  Bible,  and  feeling  particularly  comfortable,  a 
thought  having  just  come  into  his  head  that  he  would 
print  some  of  his  compositions,  he  came  to  the  fatal 
passage,  "  All  manner  of  sin  and  blasphemy  shall  be 
forgiven  unto   men  :  but  the   blasphemy  against   the 


Chap.  VII.]         The  Unpardonable  Sin.  199 

Holy  Ghost  shall  not  be  forgiven  unto  men."  Peter 
rushed  out,  his  wife  imploring  him  to  tell  her  what 
was  the  matter.  He  could  only  answer  with  groans, 
and  for  three  days  and  three  nights  he  did  little  else 
than  groan.  He  became  at  last  calm.  His  wife  per- 
sisted in  asking  him  the  cause  of  his  late  paroxysms. 
It  is  hard  to  keep  a  secret  from  a  wife,  so  Peter  told 
her  the  sad  tale  as  they  sat  one  night  over  the  dying 
brands  of  their  hearth.  He  thought  she  would  have 
shrunk  from  him  with  horror,  but  she  did  not.  She 
raised  her  eyes,  and  looking  up  in  his  face  said,  "Let 
us  go  to  rest ;  your  fears  are  groundless. " 

Peter  was  cured,  and  became  one  of  the  most  cele- 
brated, devoted,  zealous,  and  successful  of  Welsh 
missionaries. 

It  will  be  seen  in  this  case  that  a  man,  who  ap- 
peared otherwise  sane,  had  become  fully  impressed,  by 
means  of  his  early  religious  education  and  surroundings, 
with  the  idea  that  there  was  an  unpardonable  sin 
against  the  Holy  Ghost,  and  that  in  boyhood  he  had 
committed  it.  Whatever  the  delusion,  the  same 
egotism  exists;  the  patient  invariably  says  he  is  the 
only  person  who  ever  acted  thus,  and  that  there  can 
be  no  possible  hope  for  him.  The  feeling  seems  to 
arise  in  at  least  two  different  ways;  in  one  a  very 
stormy  voice  of  conscience  appears  for  ever  to  be 
trumpeting  in  the  ears  of  the  unfortunate  patient  that 
he  is  lost ;  and  in  the  other  case  (and  this  is  most 
common  among  younger  patients)  there  is  a  feeling 
of  deadness,  a  feeling  that  nothing  arouses  them  to  a 
sense  of  their  sin.  They  will  write  long  letters, 
saying  they  feel  they  must  be  cast  away,  because  they 
know  they  have  committed  grave  crimes,  but  yet  they 
do  not  feel  any  real  sorrow  for  their  act.  and  this 
proves  they  are  the  unpardonable  sinners  ;  they 
had  neglected  their  opportunities,  and  the  time 
for  turning  has  passed.      Such  cases  are  looked  upon 


200       Insanity  and  Allied  Neuroses,  [Chap.  vn. 

generally  as  very  vinfavourable  ;  but,  in  my  experience, 
a  fair  proportion  get  well,  although  it  may  take  years 
before  they  recover,  the  prognosis  depending  to  a 
great,  extent  on  the  age  and  general  health.  The 
majority  of  young  cases,  if  there  be  no  chest  disease, 
recover.  A  large  proportion  of  the  middle-aged 
cases,  especially  those  following  lactation,  also  recover. 
Many  suffering  from  melancholia  occurring  at  the 
climacteric  recover,  but  require  some  time  for  the  re- 
establishment  of  perfect  health.  In  senile  cases  the 
prognosis  is  still  worse.  Many  cases  after  middle 
age  slowly  sink  and  die,  while  others  will  remain 
wretched  and  unoccupied,  and  end  in  weak-minded- 
ness. Again,  others  will  improve  in  physical 
health,  while  their  mental  actions  grow  restricted, 
and  they  become  automatic  "  miserable  sinners," 
such  as  are  represented  by  one  patient  now  in 
Bethlem,  who  says  nothing  but  "  dead  and  damned." 
The  only  treatment  available  in  such  cases  must 
be  of  a  general  character,  and  must  be  regulated 
according  to  the  age  and  physical  state  of  the  patient. 
In  the  younger  cases,  iron,  quinine,  and  mineral  acids, 
with  saline  purgatives,  such  as  mineral  waters,  taken 
the  first  thing  in  the  morning,  are  sometimes  useful. 
In  the  climacteric  cases,  tonics,  stimulants,  morphia, 
and  purgatives  are  of  service.  I  rarely  give  bromide 
of  potassium  or  chloral  hydrate.  In  a  few  cases  where 
exhaustion  was  extreme  ten  grains  of  chloral  hydrate, 
with  half-an-ounce  of  brandy  every  two  hours,  proved 
of  service.  In  senile  cases,  rest  in  bed  with  good  food 
and  small  repeated  doses  of  morphia  are  beneficial. 
Some  physicians  consider  that  the  treatment  of  severe 
cases  of  melancholia,  such  as  are  seen  among  the  un- 
pardonable sinners,  is  best  followed  if  the  patient  be 
kept  in  bed. 

■  At    the    climacteric   period    considerable    mental 
disturbance    arises  \   it    is    generally   melancholic    or 


Chap.  VII.] 


Senile  Mela  nchol la  . 


2QJ 


delusional  in  type,  both  in  men  and  women.  I  must 
confess  that  the  evidence  in  favour  of  a  distinct 
climacteric  period  in  men  is  not  quite  convincing. 

Senile  iiielaiicliolia.  —  With  old  age  come 
many  troubles,  and  the  so-called  "  weight  of  years  " 
may  be  but  another  name  for  sadness  of  heart.      "The 


A  case  of  Senile  Melancliolia. 

almond-tree  shall  flourish,  and  the  grasshopper  shall 
be  a  burden,  and  desire  shall  fail :  because  man  goeth 
to  his  long  home,  and  the  mourners  go  about  the 
streets  :  or  ever  the  silver  cord  be  loosed,  or  the 
golden  bo\\d  be  broken,  or  the  pitcher  be  broken  at  the 
fountain,  or  the  wheel  broken  at  the  cistern."  The 
machine  is  wearing  out,  and  vdth  the  wear  there  is 
conscious    painful    sensation    connected    with    almost 


2  02       Insanity  and  Allied  Neuroses.  [Chap.  vii. 

every  act.  All  sprightliness  and  spontaneity  of  life 
have  passed.  Even  tlie  conservative  period  of  order 
and  method  is  now  over,  and  the  few  things  that  can 
be  done  are  limited  in  every  direction  by  pain  oi 
feebleness.  Although  wear-out  will  have  to  be  con- 
sidered also  in  connection  with  dementia,  there  is 
also  a  condition  of  painful  action  and  sensation, 
such  as  may  be  described  by  the  term  senile  melan- 
cholia. It  appears  sometimes  rather  suddenly,  as 
the  result  of  some  family  distress  or  domestic  loss. 
Thus  a  man  of  eighty-four  years  of  age,  who  had 
shown  no  signs  of  insanity,  lost  his  wife  within  a  few 
months  of  their  keeping  their  golden  wedding,  after 
which  the  poor  old  man,  brooding  over  his  loss,  and 
feeling  his  solitude,  developed  the  idea  that  he  had 
killed  his  wife,  and  must  now  destroy  himself.  Rest 
and  change  of  surroundings,  with  suitable  companions, 
restored  his  peace  of  mind,  and  he  spent  the  rest  of 
his  life  in  mental  health. 

In  another  case  a  merchant  sustained  a  very 
serious  loss  in  a  speculation,  and  brooding  alone  over 
his  misfortune,  developed  melancholia,  and  contem- 
plated suicide.  Change  of  scene  for  a  time  relieved 
him ;  but  a  return  to  his  office  was  associated  with  a 
re-development  of  the  melancholic  symptoms,  which 
finally  carried  him  off.  In  senile  cases  the  age  must 
be  considered  relatively  to  the  character  of  the  indi- 
vidual physique ;  for  we  meet  with  men  who  are  worn 
out  at  forty,  and,  on  the  other  hand,  there  are  active 
men  possessing  the  energies  of  middle  age  at  seventy. 
I  should  say  the  reality  of  age  depends  as  much,  or 
more,  on  the  arteries  as  on  the  years.  I  have  been  often 
struck  with  the  arterial  changes  which  are  visible  in 
one  form  or  another  of  mental  disease.  The  rigid 
artery  may  be  associated  with  other  diseased  vascular 
conditions  ;  among  other  things,  with  bad  nutrition 
of  the  brain.       Or  we  may  meet  with  g rosser  cerebral 


Chap  VII.]  Chronic  Melancholia.  203 

changes  in  connection  with  apoplexy,  and  which  we 
shall  consider  later  under  a  special  heading.  I  must, 
however,  here  say  that  I  have  seen  several  cases  in 
which  there  was  marked  mental  depression  preceding 
attacks  of  apoplexy  in  patients  with  diseased  arteries. 
I  saw  one  doctor,  who  suffered  from  constant  sub- 
jective annoyance  through  his  ears,  his  nose,  and  his 
skin  for  months  before  his  fatal  attack  of  apoplexy. 
In  some  other  cases  of  senile  melancholia,  mental  or 
bodily  hypochondriasis,  with  great  emotional  disturb- 
ance, is  met  with  ;  and  it  is  not  unknown  for  patients 
of  advanced  years  to  destroy  themselves,  being  con- 
vinced they  have  outlived  their  time. 

The  prognosis  of  senile  melancholia  must  depend 
upon  the  inheritance,  and  the  general  physical  con- 
dition of  the  patient.  If  the  arterial  tension  be 
high,  and  if  there  be  alb^imen  in  the  urine,  the 
prognosis  must  necessarily  be  bad.  If  the  patient 
have  already  had  other  attacks  of  insanity  or  apo- 
plectic seizures,  the  prospect  is  likewise  dark.  If, 
however,  the  general  health  be  good,  the  appetite 
maintained,  and  the  patient  easily  induced  to  try 
change  in  surroundings  and  companionship,  he  may, 
with  general  care  as  to  hygienic  treatment,  get  well, 
even  though  he  has  passed  fourscore  years. 

The  consideration  of  melancholia  would  be  in- 
complete if  I  did  not  refer,  at  least  incidentally,  to 
cases  of  chronic  melancholia,  to  cases  of  recurring 
melancholia,  and  to  cases  in  which,  after  many  years 
of  depression,  patients  have  recovered.  Properly,  the 
first  two  groups  will  fall  under  the  class  of  weak- 
mindedness  or  chronic  insanity,  but  yet  there  are 
grounds  for  taking  them  out  of  this  class  and  con- 
sidering  them  specially.  Chronic  melancholia  may  be 
of  any  one  of  the  above  varieties ;  and,  as  I  have 
pointed  out,  w« .  may  meet  with  cases  of  active 
melancholia,  in  which  the  patients  will  go  on  wringing 


204       Insanity  and  Allied  Neuroses.  [Chap.  vii. 

their  hands  and  pulling  their  hair,  year  after  year, 
only  speaking  monotonously  about  the  misery 
they  are  suffering,  till  I  suppose  (for  I  have  not 
had  the  opportunity  of  watching  such  a  case  be- 
yond ten  years)  they  become  ultimately  mere  auto- 
mata and  weak-minded  in  every  respect.  The  other 
cases  in  which  melancholia  recurs  differ  only  in 
degree  from  those  which  have  several  distinct  at- 
tacks of  melancholy  and  completely  recover,  being 
discharged  after  each  recovery  from  the  asylum.  In 
Bethlem  we  have  on  the  incurable  list  about  six  or 
seven  cases  of  this  variety,  patients  who,  perhaps 
fifteen  or  sixteen  years  ago,  were  admitted  suffering 
from  profound  melancholia  with  suicidal  tendencies, 
refusal  to  take  food,  and  delusions  as  to  unworthiness. 
They  recovered,  and  were  discharged  from  the  hospital 
only  to  relapse  almost  as  soon  as  they  were  restored 
to  their  old  surroundings.  Again  they  recovered, 
but  on  each  restoration  to  home  and  duties  they 
broke  down,  and  in  consequence  of  this  inability 
to  fit  themselves  into  their  old  relationships, 
they  necessarily  became  permanent  inhabitants  of 
an  asylum.  Here  they  pass  a  fairly  contented  and 
useful  life,  every  few  years  developing  their  old 
melancholia,  and  for  varying  periods  consider  them- 
selves to  be  miserable  sinners  or  persecuted  victims. 
What  the  brain  pathology  of  such  conditions  can  be 
remains  a  perpetual  puzzle  to  me.  That  a  lady 
should  for  two  years  be  amiable,  agreeable,  trust- 
worthy, without  any  special  peculiarity  of  any  kind, 
and  should  be  allowed  to  go  in  and  out  of  the  asylum 
with  perfect  freedom  during  this  time ;  and  that  she 
then  should  slowly  become  a  wretched  suicidal  melan- 
choliac  for  twelve  months,  and  once  again  recover, 
only  in  a  few  years  more  again  to  pass  under  the 
wave  of  depression,  still  remains  a  puzzle.  The  end 
of  such  cases,  I  believe,  is  generally  mental  weakness  ; 


Chap.  VII.]  Chronic  Melancholia.  205 

and  if  this  be  so,  I  suppose  each  attack  reduces  the 
intellectual  powers  a  little.  Cases  such  as  these  lead 
me  to  the  consideration  of  the  last  group,  the  cases 
of  retarded  recovery. 

In  one  case  symptoms  of  melancholia  occurred  in 
a  woman  35  years  old,  without  children,  whose  mother 
was  in  an  asylum,  and  whose  husband,  then  nervous, 
afterwards  died  of  general  paralysis.  This  woman 
was  admitted  believing  herself  to  be  utterly  wicked, 
and  that  she  had  acted  inhumanly  in  allowing  her 
insane  mother  to  be  sent  to  an  asylum.  She  was  al- 
ways contemplating  suicide.  There  was  a  combina- 
tion by  this  patient  and  another  to  secure  sufficient 
rope  to  hang  them  both ;  but  fortunately,  when  one 
managed  to  get  a  piece  of  rope  with  which  to  effect 
their  purpose,  the  other,  the  patient  now  under  con- 
sideration, not  only  declined  to  hang  herself,  but  gave 
information  which  prevented  her  fellow-conspirator 
from  carrying  out  her  purjDOse.  Year  after  year 
passed  without  any  amelioration  in  the  symptoms  of 
this  patient.  She  was  always  insisting  that  she  must 
go  out  and  be  hanged;  only  varying  this  with  the 
statement  that,  as  society  would  not  recognise  her 
right  to  be  hanged,  she  must  go  out  and  murder  a 
man,  and  then  it  would  be  all  right.  After  several 
changes  in  her  relationship  to  the  other  patients  and 
attendants,  she  was  moved  into  an  entirely  new 
gallery,  where  the  change  had  a  wonderfully  beneficial 
effect.  I  was  able  to  send  her  on  leave  of  absence, 
and  she  ultimately  recovered  and  has  remained  well 
and  grateful  for  some  years. 

A  still  more  remarkable  case  was  that  of  a  man 
who  was  admitted  in  Bethlem  on  the  27th  September, 
1834,  and  who  was  a  patient  in  Bethlem  for  thirty- 
lour  years,  and  for  fifteen  years  sat  with  his  head 
bent  upon  his  chest,  apparently  regardless  of  every- 
•-hing    about    him,  yet  one  felt  sure,  from  incidental 


2o6       Insanity  and  Allied  Neuroses.  [Chap.  vii. 

circumstances,  that  he  really  did  perceive  what  was 
transpiring,  and  that,  therefore,  his  condition  was 
one  of  melancholy  and  not  one  of  weak-mindedness. 
One  evening,  when  sitting  in  the  billiard-room  with- 
out taking  any  interest,  he  began  to  look  about  him  ; 
a  few  days  after  he  was  cheerful,  in  fact  almost 
exuberant,  and  onlthe  14th  of  May,  1879,  was  dis- 
charged recovered,  and  has  remained  well  since. 

I  shall  consider  later  the  mental  symptoms 
associated  with  suppressed  gout  and  visceral  diseases. 
Melancholia  may  occur  with  renal  disease  and  with 
heart  disease.  Melancholic  symptoms  are  not  un- 
common with  displacements  of  the  uterus  and  with 
uterine  fibroids.  Losses  of  the  special  senses  may 
lead  to  nervous  irritability,  suspicion,  and  depression ; 
in  several  cases,  facial  deformities,  and  the  shyness 
connected  therewith,  have  been  traceable  as  causes  of 
melancholy,  frequently  with  suicidal  and  homicidal 
tendencies. 

As  far  as  the  diagnosis  is  concerned,  there  are  few 
points  to  which  I  need  specially  refer.  I  have  said 
that  melancholia  is  mental  pain,  out  of  relationship 
to  the  surroundings;  but  from  time  to  time  cases  are 
seen  in  which  men  of  good  position  and  of  undoubted 
reputation  say  they  are  too  wicked  to  live,  that  they 
are  hypocrites  and  the  like,  and  in  some  such  casfs 
the  penitent  defaulting  trustee,  not  the  melancholic 
patient,  is  to  be  seen. 


207 


CHAPTER  VIII. 

DEMENTIA ACUTE  DEMENTIA. 

General  or  partial — Primary,  from  injury  or  shock— Secondary, 
(a)  to  physical  conditions  ;  (6)  mental  disorder— Typical  general 
dementia — Partial  dementia,  loss  of  appetite,  loss  of  will- 
power —Loss  of  memory — Dementia,  secondary  to  fever,  pneu- 
monia, child-birth,  injuries,  alcoholism,  epilepsy,  age. 

In  considering  dementia  I  shall  make  two  clear  divi- 
sions. In  one  there  is  destruction  more  or  less  com- 
plete of  the  mind,  which  can  never  be  recovered  from, 
and  in  the  other  there  is  functional  arrest,  which  may 
pass  off. 

Both  conditions  appear  the  same  to  the  ordinary 
observer,  just  as  is  the  case  with  conditions  of  real  or 
apparent  paralysis  seen  in  hysteria. 

I  shall  describe  dementia  in  its  several  forms,  in- 
cluding both  these  types ;  and  also  refer  to  its  various 
causes,  and  later  I  shall  consider  the  partial  insanities 
which  have  been  usually  placed  under  the  head  of 
weak-mindedness. 

As  mental  life  begins  with  but  little  evidence  of 
intellect,  and  with  imperfectly  organised  sense  im- 
pressions and  motor  impulses,  so  it  may  end  with  a 
return  to  its  simplicity  in  age.  At  the  one  end  of 
life  there  may  be  inability  to  develop  intellectually ; 
this  is  called  amentia;  and  at  the  other  end  destruc- 
tion of  mind  may  leave  the  whole  intellectual  fabric  a 
ruin ;  this  is  called  deme^itia. 

Ko  two  houses  fall  into  ruins  in  exactly  the  same 
way,  though  in  the  end  the  four  walls  alone  may 
remain  as  evidence  of  the  once  inhabited  dwelling ; 
and  so  with  mental  destruction,  it  will  be  found  that 


2o8      Insanity  and  Allied  Neuroses.  [Chap.viii. 

though  in  the  end  similar  foundations  and  simple 
boundaries  of  mind  may  remain,  all  the  finer  parts 
are  removed ;  whether  age,  war,  or  fire  has  destroyed 
the  houses,  the  results  are  alike ',  similarly,  either 
age,  disease,  or  injury  may  wreck  the  mind.  It  will 
be  seen  that  the  mind  may  show  the  effects  of  destruc- 
tion in  various  ways,  and  the  destruction  may  progress 
at  very  different  rates. 

There  is  no  such  thing  as  complete  dementia,  for 
life  could  not  exist  with  total  suppression  of  mind 
and  sense  reaction  ;  but  there  are  varieties  of  dementia 
in  which  most  of  the  parts  of  mind  exhibit  signs  of 
weakness,  and  this  I  shall  call  general  dementia^  in 
contrast  with  the  partial  dementia  which  will  be 
shown  to  affect  special  parts  or  factors  of  mind. 

Cases  of  dementia  sbould  be  to  the  mental  philo- 
sopher like  analysis  to  the  chemist,  or  like  weathering 
of  rocks  to  the  geologist.  Dementia,  by  separating 
and  isolating  certain  faculties,  and  by  interfering  with 
the  action  of  mind  enables  one  to  get  a  clearer  view  of 
mind  than  is  to  be  gleaned  from  the  study  of  the 
normal  mind  in  healthy  action. 

By  studying  aberrant  development  and  partial 
dementia,  much  will  be  learnt  which  can  only  be 
hinted  at  in  a  book  intended  for  students. 

Dementia  is  to  be  divided  into  prmiary  or 
secondary.  Comparatively  few  cases  can  be  looked 
upon  as  purely  direct  and  primarv,  but  some  are 
seen,  especially  such  as  are  due  to  physical  disorders, 
as  fevers,  poisoning,  or  direct  injury.  Many  more  are 
secondary  to  other  states  of  bodily  or  mental  disorder. 

I  shall  begin,  as  I  did  in  considering  mania  and 
melancholia,  with  a  description  of  dementia  as  a 
whole.  Not  that  it  is  at  all  common  in  diseased 
any  more  than  in  normal  states  to  find  perfectly 
typical  examples. 

In    a   case  of  complete  general    dementia,    there 


Chap.  VIII.]  General  Dementia^  209 

would  be  a  general  weakness  of  the  senses,  the 
memory  and  the  higher  organising  and  controlling 
powers.  The  senses  would  react  slowly  to  their  re- 
spective stimuli,  reflex  actions  would  be  performed, 
and  in  some  cases  (in  my  experience)  the  loss  of  the 
higher  control  would  cause  reflex  action  to  be 
rendered  more  rapid  and  more  active  than  in  health. 

Many  acts  of  the  more  common  kind  would  be 
done  automatically.  The  power  of  storing  impres- 
sions would  be  greatly  impaired  or  even  annihilated, 
so  that  the  memory  for  recent  impressions  would  be 
wanting,  and  memorj"  of  the  past  would  be  some- 
what affected.  There  would  be  no  evidence  of 
volition,  and  emotional  display  would  be  rare. 

The  loss  of  self-control  and  of  general  control 
would  be  marked,  but  the  evidences  of  loss  of  self- 
control  would  not  as  a  rule  be  seen  in  display  of 
energy  along  unwonted  lines,  but  would  be  marked 
by  suppression  of  the  energy. 

That  different  amounts  of  loss  of  power  produce 
these  different  results,  I  have  often  seen  in  progres- 
sive degeneration. 

Thus  a  woman  who  had  been  badly  marked  by 
small-pox,  when  sane,  got  over  the  consciousness  of  her 
disfigurement ;  but  with  dementia  came  a  constant 
desire  to  hide  her  face,  but  as  the  dementia  became 
more  profound  she  again  disregarded  her  appearance. 

So  much,  then,  for  the  effects  of  loss  of  control. 

There  might  be  tears,  or  a  ripple  of  a  smile  might 
pass  across  the  features,  but  these  displays  of  emotion 
would  have  no  relation  to  the  surrounding  circum- 
stances. In  such  a  condition  there  could  be  no  power 
of  abstraction,  no  ability  to  judge  by  comparing  one 
thing  with  another,  nor  could  there  be  any  origination 
of  ideas.  There  generally  would  be  more  or  less  plastic 
muscular  condition  directly  opposed  to  tJie  rigid  cata- 
leptic state  which  we  have  observed  in  melancholia. 
o— 14 


210     Insanity  and  Allied  Neuroses.  [Chap.  viii. 

There  would  be  good  digestion  and  good  appetite,  with 
the  habits  frequently  dirty,  the  patients  neglecting 
themselves,  both  as  regard  urine  and  faeces.  In  such 
cases  there  would  be  absence  of  sexual  desire;  sleep 
good,  so  that  patients  would  sleep  as  soon  as  put  to 
bed,  and  would  remain  in  the  position  in  which  they 
were  left  till  morning.  Such  is  a  description  of  com- 
plete or  general  dementia,  a  very  good  example  of 
which  is  to  be  seen  in  the  following  case  : 

Case  of  acute  primary  general  dementia. — Patient 
was  single,  twenty-two,  and  a  farmer.  Two  sisters 
insane.  Admitted  March,  1873.  On  November  5,  on 
his  return  from  a  public-house,  he  was  frightened  by 
some  fireworks  which  were  thrown  at  him  as  he  went 
along  a  dark  lane.  He  got  home,  but  remembered 
nothing  about  the  journey,  nor  his  actions  after  he 
was  there.      He  was  not  drunk. 

The  next  morning  he  did  not  get  up,  and  when 
his  brother  tried  to  get  him  to  go  to  his  usual  work 
he  took  no  notice.  When  taken  out  of  bed  he  stayed 
where  he  was  placed.  His  brother  thought  it  all 
resulted  from  drink,  and  fancied  he  would  sleep  it  off. 
For  the  next  few  days  he  was  dull ;  then  for  a  short 
tiuie  and  at  intervals  he  was  violent,  and  seemed  to 
see  objects  of  dread. 

On  admission  he  was  described  as  a  fat  lubberly 
fellow,  who  neither  moved  nor  spoke ;  and  who  had  to 
be  fed,  washed,  and  tended  like  an  infant. 

He  ate  and  slept  well,  and  was  in  no  way  violent. 
The  general  idea  was  that  this  patient  had  been  weak- 
minded  from  birth.  He  occasionally  whistled  to  him- 
self, but  did  nothing  to  pass  the  time.  He  scratched 
his  face  into  sores.  The  continuous  electric  current 
was  applied  to  his  head  daily.  He  roused  after 
some  weeks,  and  said  his  first  returning  recollection 
was  of  the  galvanism.  His  mind  was  a  total  blank 
from  November  till  June   1.      He  became  not   only 


Chap.  VI 1 1 .]  Par  tia  l  Dementia  .  2  n. 

active,  but  pleasant  and  cheerful,  and  rather  over- 
demonstrative  for  a  time.  He  went  back  to  his 
work;  for  some  years  I  heard  that  he  was  well,  and 
I  have  little  doubt  that  if  he  had  broken  down 
again  we  should  have  ha  1  an  ap;)licatiun  for  his  re- 
admission. 

Partial  dementia,  occurring  as  an  acute  dis- 
order, is  supposed  to  be  uncommon.  I  am,  however, 
inclined  to  think  there  is  a  special  group  of  cases 
which  should  be  looked  upon  as  belonging  to  this  class. 
Young  adults,  who  have  given  wav  to  excesses, 
especially  when  several  varieties  of  excess  have  been 
indulged  in  at  the  same  time,  become  unable  to  per- 
form the  duties  for  which  they  have  been  educated 
and  fully  prepared,  A  young  man  of  twenty  who 
had  had  a  liberal  education,  with  a  special  training  in 
art,  and  who  was  put  to  an  artistic  calling,  overworked 
himself  and  indulged  in  masturbation ;  he  became 
unable  to  do  the  finer  parts  of  his  artistic  work. 
He  began  by  being  inattentive  ;  next  he  spoilt  the 
materials ;  and  later,  his  work  showed  no  signs  of 
any  of  his  former  artistic  knowledge  or  ability. 
He,  in  fact,  was  distinctly  losing  the  highest  and 
latest  of  his  acquirements.  Rest  for  a  short  time 
enabled  him  to  return  to  his  work ;  but  he  had  not 
sufficiently  regained  strength,  and  rapidly  relapsed 
into  his  condition  of  partial  weak-mindedness,  and 
unless  prolonged  rest  with  exercise,  good  food,  together 
with  somewhat  stimulating  companionship  and  sur- 
roundings are  provided,  the  prospect  of  the  case  is  un- 
favourable. 

One  of  the  most  common  varieties  of  partial  weak- 
mindedness  is  seen  in  the  loss  of  confidence,  so  that 
persons  who  have  hitherto  been  fully  able  to  jDer- 
form  the  duties  of  their  profession,  become  doubtful, 
uncertain,  and  incapable.  I  remember  one  case 
especially  in  which  this  was  remarkably  well  seen.    A 


212      Insanity  and  Allied  Neuroses.  [Chap.  viii. 

lawyer,  thirty-two  years  of  age,  whose  mother  had 
been  insane,  and  in  whose  family  phthisis  was  also 
present,  became  uncertain  and  doubtf\il  about  his 
ability  to  fulfil  his  duty.  He  had  had  a  slight 
attack  of  insanity  eleven  years  before,  from  which 
he  completely  recovered.  He  had  also  one  attack  of 
rheumatic  fever.  The  supposed  cause  of  his  insanity 
was  loss  of  situation,  but  the  truth  really  was  that 
he  gave  up  his  situation  because  he  felt  doubtful 
about  being  able  to  continue  his  duties.  There  was  a 
feeling  of.  unworthiness  at  one  time  in  his  case  which 
caused  me  to  look  upon  it  as  one  of  melancholia ;  and 
undoubtedly  the  symptoms  were  of  a  mixed  kind. 
But  the  most  characteristic  symptoms  were  shown  by 
his  utter  inability  to  decide  upon  any  course  of  action. 
If,  for  instance,  he  was  asked  to  lunch,  he  would  take 
twenty  minutes  to  decide  whether  he,  as  a  patient,  had 
a  right  to  accept  any  invitation  at  all,  and  if  at  last 
he  went,  half  compelled  and  half  persuaded  to  leave 
his  ward,  he  would  further  hesitate  before  taking  a 
seat,  lest  that  seat  might  be  required  by  some  one 
else;  and  then  the  meal  would  be  prolonged  to  a 
most  inordinate  leng-th  in  consequence  of  his  inability 
to  decide  upon  what  he  should  and  what  he  should 
not  do. 

After  two  years  of  treatment  he  left  to  be  under 
private  care  for  a  time,  but  again  drifted  into  an  asylum, 
whence  he  was  once  more  set  at  liberty,  and  since 
then  I  have  met  him  in  one  place  or  another  still 
vaguely  passing  from  one  thing  to  another,  but  utterly 
unable  to  decide  on  any  definite  course  of  action.  In 
this  condition  I  believe  he  will  pass  the  rest  of  his 
life ;  for  ever  weighing  motives  and  endeavouring  to 
decide  upon  what  he  should  do,  but  quite  incapable 
of  acting  freely  and  at  once.  We  see  in  this  last 
case  that  partial  dementia  may  present  itself  as  loss 
of  will. 


Chap. VIII.]  Memory  and  Mental  Faculties.    213 

Partial  and  progressive  dementia  are  found  as- 
sociated with  the  loss  of  common  sensibility ;  and 
I  shall  point  out  that  in  many  cases  of  myxoedema 
there  is  a  progressive  deterioration  of  intellectual 
power  associated  with  slow  conduction  of  impression, 
loss  of  common  sensibility,  and  general  loss  of  tem- 
perature ]  but  I  am  not  prepared  to  admit  with  Dr. 
Ord  that  this  mental  deterioration  results  alone 
from  the  loss  of  peripheral  stimulus.  I  am,  however, 
inclined  rather  to  consider  it  as  part  of  a  diseased 
process,  in  which  not  only  the  central  but  also  the 
peripheral  nervous  centres  are  affected.  Besides 
weak-mindedness  connected  with  loss  of  common 
sensibility,  there  arises  mental  degradation  connected 
with  loss  of  the  special  senses  ;  just  as  idiocy  may 
arise  from  the  want  of  hearing,  so  loss  of  hearing,  espe- 
cially if  combined  with  any  other  sense-loss,  will  tend 
to  produce  intellectual  weakening  along  certain  lines. 

Memory  is  often  taken  as  the  test  of  mental 
strength  or  weakness  ;  but  it  has  to  be  looked  upon  in 
very  different  ways.  It  is  possible  for  an  imbecile  to 
have  a  wonderful  power  of  memory.  In  fact,  the 
most  marvellous  memories  are  often  the  most  useless, 
and  are  seen  among  the  chronic  imbeciles.  Memory 
begins  to  fail  naturally  in  certain  particulars  at  about 
middle  age ;  and  memory  of  names,  of  persons  and 
places,  and  the  like,  fails  in  most  busy  men  soon  after 
forty  years  of  age.  This  is  physiological,  and  may  be 
considered  as  due  to  two  causes.  In  the  first  place 
the  middle-aged  man  has  found  the  futility  of  collect- 
ing matter  not  likely  to  be  required  later.  He  has 
not  the  same  special  interest,  and  does  not  pay  the 
same  attention  to  new  names  and  faces  as  he  did  when 
a  younger  man ;  and,  next,  there  is  doubtless  a  limit 
to  the  storing  capacity  of  the  human  brain  for 
disjointed  disconnected  facts.  Many  old  men  are 
characterised  by  a    further    degradation  of    memory, 


2  14     I^^SJ^VTV  and  Allied  Neuroses.  [Chap.  viii. 

while  repetition  and  wearisome  recalling  of  long  past 
details  are  supposed  to  be  characteristics  of  senility. 
This  may  pass  beyond  simple  functional  loss,  and  be- 
come so  marked  that  the  patient  may  require  to  be 
looked  after  and  controlled.  I  know  some  physicians 
would  strongly  oppose  the  sending  to  an  asylum  of 
patients  suffering  chiefly,  if  not  solely,  from  loss  of 
memory,  especially  if  this  occur  in  old  people  ;  but 
examples  are  occasionally  seen  in  Bethlem,  where  it 
appears  to  me  that  the  kindest  and  best  treatment  for 
senile  weak-mindedness  is  seclusion  in  an  asylum. 
Thus,  an  old  man,  seventy-eight  years  old,  when  his 
memory  and  other  faculties  were  becoming  weaker, 
married  a  young  wife,  and  indulged  in  sympathetic 
weakness  which  brought  him  pecuniarily  to  ruin.  The 
next  stage  in  his  mental  degradation  was  an  increase  of 
irritability  and  a  tendency  to  self-neglect,  so  that  be- 
coming poor,  dirty,  irritable,  and  impressionable,  he  was 
always  in  trouble.  Seclusion  for  a  time  in  Bethlem 
restored  him  to  physical  comfort ;  and  although  seclu- 
sion cannot  reduce  the  weight  of  increasing  years,  it 
nevertheless  allowed  him  to  live  in  comfort  without 
further  injuring  his  prospects,  or  causing  annoyance  or 
trouble  to  his  friends  or  neio-hbours. 

Loss  of  memory  may  follow  other  conditions  besides 
age,  and  may  be  the  chief  symptom  of  mental  disorder  ; 
and  I  feel  it  difficult  to  decide  whether  it  is  more 
correct  to  place  these  cases  among  those  of  primary  or 
of  secondary  degeneration.  In  the  following  case, 
a  woman  forty  years  old,  with  some  insanity  on 
the  father's  side,  who  had  been  exhausted  by  the  con- 
stant w^atching  and  nursing  of  a  paralysed  husband, 
doAeloj^ed  quite  suddenly  loss  of  memory  of  recent 
events ;  this  followed  a  fit,  apparently  hysterical, 
which  occurred  three  weeks  before  her  admission  into 
the  hospital.  Nothing  could  be  more  complete  than 
her    loss    of   memory,   so   that  although   told   at   one 


Chap.  VIII.]  Loss    OF   MeMORY.  21  5 

moment  a  person's  name,  condition,  and  relationship 
to  her,  she  had  the  next  moment  forgotten  en- 
tirely both  name  and  relationship.  It  was  most 
interesting  to  observe  how  purely  the  loss  of  memory 
was  a  Ijss  of  power  to  store  recent  impressions.  !She 
was  tested  in  every  way  as  to  her  memory  of  the  past. 
She  conld  give  the  German  for  any  article  which  was 
shown  to  her,  she  having  lived  some  years  ago  in 
Germany.  She  could  strike  a  note  on  a  piano  when 
told  to  do  so,  and  she  could  also  recognise  the  name 
of  a  note  when  struck.  She  had  unimpaired  power 
of  comparing  past  impressions,  so  that  she  could 
argue  in  a  way ;  and  her  ideas  as  to  the  time  of  year 
and  time  of  day  were  evidently  formed,  not  from 
memory  but  from  reason.  Thus,  if  I  asked  her  at 
five  o'clock  in  the  afternoon  of  a  day  in  November, 
what  was  the  month  of  the  year,  she  would  at  once 
look  at  the  clock,  look  out  of  doors,  then  at  the  fire- 
place, and  finding  it  was  dark,  the  leaves  withered, 
with  still  a  few  hanging  on  the  branches,  and  a  fire 
burning  on  the  hearth,  she  decided  it  must  be  some- 
where about  October,  If  asked  the  same  question 
five  minutes  afterwards  she  would  go  tlirough  the 
same  argument  with  a  similar  result.  I  tried  the 
effect  of  deep  impressions,  but  they  were  as  little 
persistent  as  the  fainter  ones,  and  I  could  not  find 
that  it  was  of  any  importance  whether  memory  was 
appealed  to  through  one  sense  or  through  another. 
A  visual  impression  was  forgotten  as  soon  as  an 
auditory  one.  A  striking  illustration  of  her  state 
was  afforded  when  she  was  told  by  her  friends 
that  her  husband  had  died.  She  burst  into  a  storm 
of  tears,  but  immediately  stopped  and  asked  what 
she  was  crying  about.  This  patient,  after  some 
time,  had  another  attack  of  loss  of  consciousness, 
associated  with  some  loss  of  power  with  change 
in    the    common    sensibility    of   the   left    side.      She 


2i6     Insanity  and  Allied  Neuroses.  [Chap.  viii. 

recovered  from  this,  and  in  no  way  appeared  better 
or  worse,  and  at  the  present  moment  she  is  in 
Bethlem  enjoying  good  health ;  but,  if  I  may  use  the 
expression,  with  complete  loss  of  memory  for  all  pre- 
sent impressions,  whether  they  appeal  to  her  through 
the  special  senses,  common  sensibility,  or  even  through 
the  organic  side.  This  last  is  evidenced  by  the  fact 
that  she  has  no  feeling  of  satiety,  and  will  continue 
to  eat  as  long  as  any  food  is  in  her  way.  It  has  been 
suggested  that  this  is  a  case  of  general  paralysis  j  but 
I  can  only  say  at  present  that  it  is  impossible  for 
me  to  satisfy  myself  that  this  is  so.  It  was  sug- 
gested by  a,t  least  one  eminent  physician  that  the 
detention  of  such  a  person  in  an  asylum  was  un- 
justifiable ;  but  my  own  feeling  distinctly  is,  that  a 
person  who  has  no  recollection  and  has  desires  and 
appetites,  is  a  person  pretty  sure,  especially  if  a 
woman,  to  get  seriously  compromised,  and,  if  she 
have  money,  to  be  injuriously  influenced,  if  allowed 
to  be  at  large. 

Dementia  may  be  due  either  to  physical 
or  mental  disease. — Physical.  —  I  often  meet 
with  cases  following  fevers  in  which  the  most 
marked  evidence  of  weakness  of  intellect  is  loss  of 
memory,  and  it  may  be  said  generally  that  loss  of 
memory  has  to  be  considered  as  the  most  important 
symptom.  After  typhoid  fever  I  have  frequently 
seen  patients  whose  memory,  for  a  longer  or  shorter 
period,  was  seriously  damaged,  and  now  and  then 
such  cases  do  not  recover,  but  steadily  pass  from  one 
stage  to  another  till  they  become  absolutely  and  per- 
manently weak-minded.  The  same  result  may  follow 
rheumatic  fever,  and  I  am  inclined  to  believe  that 
such  weak-mindedness  following  the  latter  disease 
occurs  more  commonly  in  cases  where  there  has  been 
excessively  high  temperature  j  but  of  this  I  am  not 
in   a  position   to  speak  authoritatively,    because    the 


Chap.  VII L]  Syphilis.  217 

cases  are  only  seen  by  me  after  the  acute  symptoms 
have  passed  off. 

Another  condition  very  frequently  giving  rise  to 
weak-mindedness,  is  alcoholic  'poisoning.  The  general 
effect  of  alcohol  will  be  pointed  out  to  be  gradual 
deterioration  of  mind,  beginning  with  loss  of  self- 
control,  passing  on  to  loss  of  the  moral  sense,  so  that 
every  desire  is  gratified  without  regard  to  truth, 
honour,  or  any  higher  social  feeling.  After  this  it  is 
common  to  meet  with  dulness  of  perception  and  loss 
of  memory,  the  patient  becoming  more  or  less  indo- 
lent, self-satisfied,  and  dull  to  reaction  from  without. 
This  condition  of  weak-mindedness  may  well  be  looked 
upon  as  but  the  result  of  premature  hardening  of  the 
nervous  tissues,  so  that  conduction  of  impressions  is 
retarded,  and  the  impressions  themselves  are  imper- 
fectly received  and  slowly  organised.  When  mental 
weakness,  due  to  alcoholic  poisoning,  has  got  as  far  as 
this  the  prospect  of  cure  is  very  small. 

The  next  condition  of  weak-mindedness  I  have  to 
consider  is  that  due  to  syi^hilis.  I  do  not  suppose 
there  is  anything  absolutely  specific  in  the  condition 
I  am  about  to  describe,  but  having  met  with  it  more 
frequently  in  cases  suffering  from  syphilis  than  in 
any  others,  I  deem  it  at  least  noteworthy.  A  patient 
having  had  constitutional  syphilis  some  years  before, 
becomes  apathetic,  indolent,  and  at  times  emotional 
and  entirely  unable  to  perform  his  business  or  his 
social  duties.  Such  an  one  shows  no  special  delusions, 
and  for  a  time  is  kept  at  home.  If  the  friends 
be  sufficiently  well  off  they  may  be  able  to  treat 
him  there,  but  if  he  be  the  bread-winner,  and  his 
retention  at  home  prevents  others  from  earning  the 
means  of  sustenance,  it  will  be  absolutely  necessary 
to  put  him  away.  A  patient  in  this  condition  has 
generally  marked  loss  of  expression,  a  look  of  apathy, 
not  of  misery,    which  may  be  increased  if  he   have 


2i8     /.vsAX/ry  axd  Allied  Neuroses,  rch.p.  viii. 

any  paralysis  of  a  cranial  nerve.  He  will  answer 
slowly  but  reasonably,  and  very  probably  will  say 
there  is  notliing  the  matter  with  him.  On  inquiry, 
however,  it  will  be  found  that  he  is  wet  and  dirty, 
although  there  is  no  evidence  of  paraplegia.  Such 
cases  may  remain  in  this  condition  for  years,  and  in 
some,  treatment  utterly  fails  to  do  any  good  whatever. 
Iodide  of  potassium  or  mercury  may  be  exhibited 
in  extreme  doses  without  results.  In  some  cases, 
undoubtedly  ])enefit  results,  and  that  quickly.  I 
have  seen  such  a  patient  completely  cured  and  remain 
well  for  years  after  ;  but  then  the  disease  was  almost 
certainly  connected  with  a  gumma.  What  the  change 
is  in  the  above  cases  I  do  not  know.  It  may  be  that 
there  is  some  change  in  the  arterial  walls,  some 
thickening  of  the  membranes,  or  even  interstitial 
change  in  the  brain  itself.  The  importance  of  re- 
cognising the  syphilitic  origin  of  these  cases  is 
great,  since  many  similar  ones  have  been  mistaken 
and  set  down  as  simple  ordinary  dementia  of  general 
paralysis  of  the  insane. 

Weak  -  mindedness  of  every  form  may  follow 
epilepsy,  and  will  be  considered  under  that  head.  A 
blow  on  the  head  will  produce  w^eak-mindedness,  and 
I  suppose  some  of  the  old  cases  of  sudden  suspension 
of  all  but  organic  life,  resulting  from  depressed  frac- 
tures of  skull,  may  be  looked  on  as  cases  of  acute  trau- 
matic dementia.  When,  later,  discussing  the  varieties 
of  mental  weakness,  I  shall  point  out  the  relationship 
of  dementia  to  other  forms  of  mental  disorder. 
Almost  all  acute  attacks  of  mental  disease  leave  the 
patient  mentally  enfeebled  for  a  time  at  least. 

When  speaking  of  mania  and  melancholia,  I 
pointed  out  that  there  is  often  action  and  reaction,  so 
that  a  patient  may  be  depressed  after  he  has  had  an 
attack  of  acute  mania  ;  there  will  be  found  weak- 
mindedness   more  or  less  directly  associated   with  an 


Chap.  VIII.]  Dementia  a  nd  Bodil  y  II  l  ness.         2 1 9 

acute  mental  illness.  After  a  severe  bodily  illness 
patients  feel  weak  in  body  ;  and  after  a  similar  dis- 
order of  the  mind  there  is  intellectual  weakness. 
This  condition  is,  in  my  experience,  most  common 
when  the  mental  disorder  has  been  specially  connected 
with  some  bodily  illness.  If  the  patient  has  become 
insane  after  pneu7nonia  or  a  fever,  or  if  she  be  insane 
in  consequence  of  child-birth,  the  chances  are  that 
she  will  have  to  pass  through  a  stage  of  mental 
weakness  exhibited  by  apathy,  indolence,  tendency 
to  the  neglect  of  person  and  proprieties ;  there  is  often 
a  large  appetite,  with  a  disposition  to  sleep  and  grow 
fat.  Such  condition  requires  every  means  of  external 
stimulation,  and  in  women  the  ovarian  functions 
must  be  looked  to,  as  they  are  almost  always  irregular 
or  in  abeyance.  Such  patients  should  not  be  kept 
longer  in  an  asylum  than  is  necessary.  I  have  fre- 
quently found  it  my  duty  to  force  such  weak-minded 
people  back  into  their  families,  where  they  slowly 
re-establish  their  family  relationships,  and  then  com- 
pletely recover. 

So  much,  then,  for  dementia.  I  feel  it  difficult 
to  make  a  quite  satisfactory  treatise  on  this  subject, 
because  weak-mindedness  has  to  be  considered  from  so 
many  points  of  view.  The  mere  reduction  of  mental 
power,  the  decreasing  scope  of  the  mind's  activities 
and  sympathies,  the  impaired  transmission  and 
velocity  of  thought,  and  the  diminished  reaction  of 
the  nervous  centres,  must  all  be  looked  upon  as 
evidences  of  mental  weakness.  Disease  itself  is 
the  evidence  of  weakness,  and  the  body  and  mind 
are  only  strong  when  well.  It  would,  therefore, 
have  been  quite  allowable  for  me  to  have  considered 
every  variety  of  mental  disorder  as  evidence  of 
mental  weakness  ;  but  instead  of  this  I  have  in  this 
chapter  brought  together  the  chief  conditions  which 
led  to   marked   and  direct   loss   of   power  in  one  or 


220     Insanity  and  Allied  Neuroses.  [Chap.  viii. 

more  of  the  most  prominent  faculties,  whether  arising 
from  the  bodily  or  mental  side. 

The  diagnosis  between  melancholia,  stupor,  and 
dementia  has  already  been  made,  and  the  chief 
sources  of  error  lie  in  the  diagnosis  between  perma- 
nent and  temporary  weak-mindedness.  The  cause  of 
the  illness  and  the  age  of  the  patient  must  decide ; 
if  young  there  is  fair  hope  of  recovery,  if  neither 
associated  with  epilepsy  nor  due  to  prolonged  ex- 
haustion from  masturbation.  If  alcohol  is  the  cause, 
the  prospect  is  fair,  if  there  have  not  been  several 
previous  attacks.  If  following  fevers,  pneumonia,  or 
child-birth,  the  prognosis  is  also  fair.  If  associated 
with  epilepsy,  apoplexy,  or  degeneration  of  arteries, 
the  chances  of  recovery  are  small. 

Treatment. — In  all  cases  change  of  surround- 
ings and  cheerful  stimulating  companionship  are  neces- 
sary. If  any  good  is  to  result  in  the  cases  which  are 
curable,  it  must  follow  liberal  diet  and  exercise.  As 
soon  as  I  can  trust  a  patient  who  is  suffering  from 
partial  dementia,  or  from  dementia  due  to  some  phy- 
sical cause,  I  send  him  home  on  trial,  or,  at  least, 
get  the  friends  to  visit  and  encourage  him. 

In  cases  of  young  men  suffering  from  the  effects 
of  masturbation,  every  means  must  be  used  to  give 
occupation  to  the  mind,  and  to  strengthen  the  body. 
Cold  bathing  and  gymnastics  are  good.  Drugs,  such 
as  bromide  of  potassium,  are  not  good.  Iron,  arsenic, 
and  occasional  purges,  are  more  likely  to  be  of 
service. 

In  older  cases  the  chief  care  is  to  prevent  the 
patients  from  injuring  themselves  in  body  or  estate. 
Such  cases  are  often  best  looked  after  in  private 
houses. 


221 


CHAPTER    IX. 

STATES    OP    MENTAL    WEAKNESS. 

Examples  of  chronic  insanity — Chronic  incoherence — Chronic 
mania — Weak-mindedness  with  easily  roused  fury — Weak- 
mindedness,  with  special  limited  caiDacities — Weak-minded- 
ness, with  temporary  sanity  before  a  fresh  attack  of  mania — 
Weak-mindedness,  with  a  second  attack  of  melancholia  due 
to  age — Chronic  active  melanchoha — Chi'onic  passive  melan- 
cholia —  Recurrent  melancholia,  with  tendency  to  weak- 
mindedness — Eecurrent  melancholia,  with  distinct  alteration 
in  character — Recurrent  mania,  with  but  little  intellectual 
loss — Profound  secondary  dementia,  of  fifty  years'  duration 
— Weak-mindedness,  with  persistent  delusion — Weak-minded- 
ness, with  hypochondriasis. 

In  all  asylums,  and  especially  in  the  large  county 
asylums,  there  are  many  patients  who  are  incurable, 
and  yet  who  are  fairly  useful  in  doing  the  simpler 
and  more  mechanical  work  of  an  asylum ;  without 
them  the  larger  asylums  would  prove  much  more 
costly,  as  they  are  the  hewers  of  wood  and  drawers 
of  water,  whose  services,  if  wanting,  would  have  to 
be  replaced  by  paid  labour.  Notwithstanding  their 
ability  to  perform  these  duties,  they  are  hopelessly 
insane  and  unfit  to  be  at  large.  Whether  they  have 
as  much  liberty  as  is  possible  is  another  question  not 
to  be  settled  here.  Many  such  patients  gradually 
develop  a  special  aspect,  and  are  recognisable  wher- 
ever they  are  met ;  but  this  is  not  true  of  all  persons 
suffering  from  chronic  insanity.  There  are  several 
degrees  in  which  this  chronic  mental  affection  shows 
itself. 

First,  after  an  attack  of  insanity  which  may  have 
been  maniacal  or  'melancholic,  the  mental  balance  is 
never  set  right ;  there  is  some  peculiarity  left,  some 
loss  of  capacity  or  some  loss  of  control,  which  more  or 


222      Insanity  and  Allied  Neuroses.     [Chap.  ix. 

less  influences  the  life's  history  to  the  end.  In 
its  slightest  degree  this  is  called  eccentricity  or  per- 
verseness,  and  many  patients  are  discharged  from 
asylums  as  recovered,  who  are  really  affected  to  some 
slight  extent  but  not  enough  to  justify  detention, 
though  the  aiSection  is  too  great  to  permit  of  a  return 
to  former  occupations.  I  have  known  active  men  of 
business,  who,  after  an  attack  of  insanity,  have  ap- 
peared well  and  rational,  but  all  power  of  application 
to  work  had  gone.  In  others,  evidence  of  loss  of 
control  was  seen  in  intemperance  or  moral  instability. 

Doubtless  a  whole  series  of  such  cases  could  be 
arranged,  exhibiting  every  degree  of  loss  of  mental 
power.  One  interesting  fact  is,  that  from  the  result 
you  cannot  judge  of  the  nature  of  the  mental  storm 
which  has  raged.  A  man  may  be  eccentric  or  intem- 
perate as  a  result  of  mania  or  melancholia. 

Attacks  of  insanity,  especially  if  they  are  repeated, 
tend  to  alter  the  whole  mental  life. 

The  alteration  may  be  slight,  affecting  the  finer 
social  adjustments,  or  may  be  grave,  destroying  all 
social  qualities.  The  alterations  may  leave  a  nervous 
instability,  which  is  shown  in  greater  readiness  to 
break  down  under  slight  causes  of  disturbance,  and  I 
shall  give  examples  of  this  as  seen  in  weak-minded 
persons,  subject  either  to  recurrent  attacks  of  violence 
or  who  are  liable  at  irregular  intervals  to  passionate 
uncontrolled  outbreaks. 

Such  patients,  though  in  the  intervals  apparently 
sane,  are  ever  ready  to  do  some  dangerous  or  violent 
act.  These  dangerously  insane  persons  may  be  able  to 
read,  write,  and  talk  as  well  as  ever,  they  may  retain 
certain  accomplishments,  and  yet  are  not  safe  to 
be  at  large.  No  single  examination  by  a  doctor  could 
satisfy  him  that  ma,ny  of  these  persons  require  special 
care,  and  that  they  are  not  fit  for  liberty. 

Attacks    of    insanity    may    leave    the    patient    a 


Chap.  IX.  1       Chronic  Incurable  Lunatics.         223 

complete  wreck,  or  they  may  leave  as  a  result  minds 
with  altered  adjustments,  so  that  in  one  case  the 
lower  or  more  organic  part  of  man  has  an  inordinate 
power,  while  in  another  this  same  organic  life  may 
be  so  deficient  as  to  endanger  the  life  of  the  man.  In 
other  cases  attacks  of  insanity  leave  a  few  promi- 
nent delusions,  which  may  be  morbid  outgrowths  of 
the  disturbed  nervous  system  ;  I  might  say  natural 
growths,  from  the  delusions  of  the  acute  disorder; 
or  they  may  be  growths  developing  from  the  lower 
parts  of  the  man's  nature,  unrestrained  by  his  higher 
powers,  growing  from  absence  of  control.  Thus  cases 
of  monomania  may  arise. 

Besides  the  above  cases,  due  to  disease,  natural 
progressive  decay  in  neurotic  subjects  may  give  rise  to 
all  sorts  of  chronic  perversions,  and  to  states  of  mental 
weakness  of  various  kinds. 

There  are  many  other  groups  of  cases  which  might 
be  referred  to.  In  some  with  strong  inheritance  a 
strong  bias  sets  in  at  certain  ages,  which  may  lead  to 
the  special  overgrowth  of  one  side  of  a  man's  charac- 
ter, and  may  thus  overbalance  his  mind.  In  some 
cases  sense-perversion  seems  at  the  root  of  the  dis- 
turbance. The  two  chief  points  in  which  cases  be- 
longing to  the  above  groups  agree  are  their  inability 
to  fulfil  their  old  functions,  and  their  perversion  of 
social  feelino^s. 

I  shall  begin  with  a  description  of  some  of  the 
cases  of  chronic  incurable  lunatics ;  those  who  have 
survived  the  storm,  but  are  mental  wrecks. 

For  convenience  I  shall  briefly  trace  the  develop- 
ment of  examples  of  such  cases  from  the  beginning.  A 
full  clinical  description  of  any  one  case  would  be  im- 
possible ;  for  as  soon  as  the  mental  storm  has  ceased, 
and  the  patient  has  passed  into  a  condition  of  chronic 
mental  unsoundness,  the  life  passes  monotonously,  and 
with  comparatively  few  changes,  lasting  often  to  an 


2  24     Insanity  and  Allied  Neuroses.     [Chap.  ix. 

extreme  length,  so  that  on  the  incurable  fund  of 
Bethlem,  as  on  a  pensioners'  list,  there  are  always 
aged  survivors. 

Characteristic  case  of  chronic  maiiia. — A  woman, 
was  forty-one  years  of  age  at  the  time  of  her 
admission  into  Bethlem  in  1847.  She  was  the  wife  of 
one  of  Her  Majesty's  household.  She  had  an  attack 
of  insanity  when  twenty- three  years  old.  As  a 
girl  she  had  been  a  circus  rider  of  considerable 
personal  attractions,  and  of  distinction  in  the  ring. 
She  married,  but  had  no  children.  She  became 
affected  by  melancholia,  and  had  ideas  that  through 
some  fault  of  hers  her  husband  was  ruined.  She 
attempted  to  strangle  herself.  Before  admission 
for  a  time  she  was  intemperate.  The  condition  of 
melancholy  continued  for  years,  so  that  she  would 
sit  about  the  wards  unoccupied,  taking  no  interest 
in  what  was  passing  around  her,  eatiug  but  little 
food,  quiet,  and  sleepless  at  night.  After  a  pro- 
longed period  of  mental  depression  she  had  a  corre- 
spondingly prolonged  period  of  mental  excitement ; 
she  became  dangerous  and  violent,  and  her  language 
was  abusive  and  obscene.  She  is  described  as 
being  a  very  demon  when  roused.  She  was  full 
of  delusions,  said  she  had  been  killed  in  various  ways, 
and  was  also  possessed  by  the  idea  that  she  was 
very  wealthy.  When  first  I  knew  her,  in  1865,  she 
was  the  terror  of  the  ward,  and  I  have  frequently 
seen  her  attack  attendants  and  medical  officers  in  an 
extremely  brutal  way.  She  at  that  time  traced,  and 
still  traces,  some  connection  between  the  Boyal  Family 
and  herself,  and  would  take  a  visitor  up  to  a  picture  of 
the  Queen,  and  say,  "  That  is  me  when  I  was  a  child." 
Incoherence,  violence,  and  coarse  language  were  the 
order  of  the  day  for  years ;  but  I  determined  to  re- 
move her  from  the  companionship  of  the  noisy  and 
acute  cases  with  whom  she  had  associated  for  over 


ch  ap .  1 X.  ]         Dementia   \vi  th  Ma  iyia  .  225 

thirty  years,  and  place  her  in  a  small  infirmary  in 
which  were  only  five  quiet  cases.  The  result  has  been 
satisfactory  in  so  far  that,  although  her  tongue  has  not 
ceased  from  abuse,  her  language  is  less  coarse,  and 
her  dress  and  mode  of  life  much  more  satisfactory 
than  when  she  was  acting  in  harmony  with  her  more 
boisterous  surroundings.  General  incoherence  with 
hallucinations  are  the  present  symptoms  of  her  mental 
condition.  When  spoken  to  she  will  talk  in  a  rather 
strident  voice  volubly  about  ''  soldiers,"  "  keep," 
''scrape,"  and  other  things  which  to  us  seem  discon- 
nected. Her  dress  is  quaint.  She  will  constantly 
appeal  to  the  "  invisibles,"  who  appear  in  her  case  to 
address  her  generally  from  the  chimney.  She  has 
apparently  lost  any  real  notion  of  age  and  general 
conditions  of  society,  so  that  she,  at  Christmas,  on 
receipt  of  a  card  with  a  cherub,  will  think  that  it  re- 
presents a  baby  which  she  is  going  to  have  ;  her  erotic 
tendencies  are  not  extinct,  and  she  is  still  dreaming 
of  marriage.  Little  disturbs  her  beyond  some  defect 
in  the  quantity  or  quality  of  her  food.  When  ex- 
cited she  is  easily  roused  to  anger.  She  has  no  real 
affection  for  those  about  her,  nor  does  she  dwell  w^ith 
any  fondness  of  memory  upon  the  husband  of  her 
youth.  Her  general  health  is  good,  and  in  this  con- 
dition of  babbling,  unstable  weak-mindedness,  ex- 
hibited by  incoherent  chatter,  she  will  live  till  some 
unexpected  bodily  ailment  carries  her  off.  The  case, 
then,  is  one  in  which  a  second  attack  of  insanity  was 
marked  by  prolonged  melancholia,  which  passed  into 
chronic  weak-mindedness,  associated  with  maniacal 
outbursts. 

Dementia  with  outbursts  of  mania. — Half  of  the 
work  of  county  asylums  is  done  by  patients  who 
belong  to  the  above  class.  I  am  in  the  habit  of 
pointing  out,  as  I  go  round  the  wards,  those  whom 
I  call  my  advanced  specialists,  patients  who  will  only 
p— 14 


2  26  Insanity  AND  Allied  Neuroses.  [Chap.  ix. 

perform  certain  limited  actions.  Thus,  one  woman  for 
many  years  polishes  or  scrubs  the  floors,  while  another 
is  only  happy  fitting  stones  or  pebbles  into  gaps  in  the 
paths.  Such  represent  the  patients  I  am  now  re- 
ferring to.  If  left  alone  they  will  behave  quietly,  but 
any  interference  with  them,  esj)ecially  if  it  involve 
change  in  their  habits  or  occupations,  will  be  violently 
resisted.  I  sometimes  compare  the  mental  state  of 
such  cases  to  that  of  a  mountain  lake,  on  which  a  very 
small  storm  will  produce  a  large  amount  of  distur- 
bance.     The  following  is  a  striking  example  : 

William   E ,   a    musician,  aged  thirty-two  on 

admission  ;  was  placed  to  the  incurable  list  in  1847, 
and  from  the  first  he  was  reported  as  dangerous  until 
thoroughly  kno^vn,  and  even  then  hard  to  manage.  He 
declined  to  recognise  his  surname,  and  always  when 
spoken  to  replied  in  an  affected  way.  If  his  surname 
happened  to  be  mentioned,  and  if  he  were  in  a  good 
temper,  he  would  say,  "  That  man  Bill  E.,  of  whom  you 
speak,  was  removed  from  here  long  ago ;  I  have  only 
just  come  ;  I  am  Wilberforce  or  Guelph,  the  redeemer 
of  the  tribe  of  Judah."  He  used  to  stand  on  iron  if 
he  could  find  any  about  the  wards,  and  would  rub  the 
back  of  his  head  to  carry  off  the  electricity  with  which 
he  said  he  was  charged,  and  would  stuff  the  left  side 
of  his  nostril  to  prevent  the  electricity  from  flowing 
into  his  penis.  A  thunderstorm  had  a  most  violently 
disturbing  influence  upon  him,  so  that  it  was  always 
necessary  at  such  times  carefully  to  avoid  him.  In 
this  condition  of  delusions,  with  loss  of  identity^  ex- 
treme irritability,  and  tendencies  to  violent  outbuists, 
he  lived  till  1879,  when  he  died  from  an  attack  of 
bronchitis. 

These  cases  serve  as  good  examples  of  the  danger 
which  would  arise  from  following  too  generally  the 
advice  so  freely  given,  to  keep  cases  of  chronic 
insanity  out  of  asylums.      Certain  patients,  no  doubt^ 


Chap.  IX.]  Chronic  Mania.  227 

can  be  as  well  treated  at  home  or  in  villages  as  ia 
asylums,  but  it  would  be  an  extremely  dangerous 
experiment  to  try  to  keep  at  large  patients  who  are 
liable  to  outbursts  of  fury  occurring  without  warning; 
or  those  who  are  disturbed  by  the  slightest  emotional 
storm,  and  who  would  inflict  serious  injury  when 
enraged,  and  yet  can  in  no  way  be  influenced  by 
dread  of  punishment  or  by  ideas  of  responsibility. 

Cases  of  chronic  mania  may  remain  as  useful 
drudges  for  years,  and  then  a  fresh  attack  of  acute 
insanity  may  occur,  leaving  the  patient  more  weak- 
minded,  more  liable  to  recurrences  of  excitement ;  or 
in  the  second  onset  of  acute  insanity  the  whole  aspect 
may  be  changed. 

Case  of  weak-mindedness,  with  temporary  return 
to  sanity  on  the  outbreak  of  a  fresh  attack  of  mania. — 
Thomas  H.,  aged  53,  a  clerk,  having  no  insane 
relations,  was  first  attacked  by  insanity  in  1866,  and 
was  taken  to  the  Exeter  asylum.  The  attack  began 
with  exalted  ideas.  He  insisted  in  carving  and 
presiding  at  every  dinner-table ;  told  his  friends  that 
he  owned  Buckingham  Palace,  and  that  the  world  and 
the  sun  obeyed  his  all-powerful  control.  From  this 
acute  state  he  passed  into  one  of  happy,  contented 
weak-mindedness,  which  lasted  for  several  years,  and 
it  is  reported  that  the  superintendent  saw  no  prospect 
of  any  change.  One  day  he  began  to  talk  quietly 
about  his  past  life,  and  toDk  an  interest  in  his  family 
and  business  relationships.  He  wrote  several  sensible 
letters,  and  made  enquiries  as  to  the  welfare  of  those 
connected  with  him.  This  period  lasted  under  two 
weeks,  when  he  became  violently  maniacal  with  exal- 
tation of  ideas,  sleepless,  restless  excitement  in  which 
he  was  constantly  occupied  in  converting  his  pillow 
into  the  Prince  Consort ;  the  excitement  showing  no 
signs  of  abatement,  he  was  transferred  to  another 
asylum  in  a  state  of  chronic  mania. 


2  28  Insanity  and  Allied  Neuroses.  LChap.  ix. 

Case  in  which  a  fresh  attack  of  melancholia 
followed  years  of  quiet  contented  weak-minded7iess. — 
John  C,  a  farm  bailiff,  aged  39,  was  admitted  into 
Bethlem  in  1861,  suffering  from  a  first  attack  of 
insanity,  said  to  have  been  associated  with  an 
ulcerated  leg.  It  began  with  melancholic  symptoms, 
alternating  with  excitement,  and  with  ideas  that  he 
was  being  poisoned.  For  the  next  ten  years  his 
symptoms  became  those  of  the  ordinary  weak-minded 
drudge.  From  morning  to  night  he  was  tidying, 
scrubbing,  and  putting  his  room  in  order.  He  was 
allowed  great  liberty,  so  that  he  wandered  about  the 
grounds  collecting  trifles,  and  latterly  took  to  repair- 
ing the  paths  in  the  gardens.  This  occupation  seems 
to  have  given  him  endless  satisfaction  and  pleasure, 
and  the  elaborate  way  in  which  he  arranged  every 
particular  stone  in  the  place  he  wished  it  to  occupy, 
formed  a  good  instance  of  a  power  for  application 
to  detail  connected  with  absolute  weak-mindedness. 
Without  any  warning,  on  the  10th  of  February,  1883, 
he  became  torpid  and  was  anxious  to  stop  in  bed. 
When  spoken  to  he  said  the  devil  had  got  hold  of 
him,  and  no  amount  of  coaxing  or  persuasion  would 
induce  him  to  resume  his  old  occupations.  On  investi- 
gation I  found  he  was  markedly  more  feeble,  his 
arteries  more  rigid,  and  his  respiration  less  free  than 
formerly.  There  appeared  to  be  a  general  reduction 
of  physical  power,  associated  with  melancholia. 

It  is  well  also  to  remember,  that  although  many  of 
these  cases  of  chronic  mania  seem  to  be  quiet  and 
harmless,  yet  many  of  them  have  acquired  habits 
quite  incompatible  with  their  being  at  large.  Thus, 
one  patient  in  Bethlem,  who  was  of  gentle  birth  and 
of  superior  education,  although  now  a  useful  aid  and 
thoroughly  trustworthy  in  many  respects,  is  given 
not  only  to  irritating  and  pinching  other  patients, 
but  has  habits  of  collecting  rubbish,  filth,  and  the  like 


Chap.  IX.]  Chronic  Melancholia.  229 

in  his  pockets.  Some  lose  all  delicate  sensibility,  so 
that  one  will  swallow  leaves,  filth,  or  other  refuse, 
while  another  will  expose  his  penis  on  every  occasion. 

Conditions  of  weak-mindedness  associated  ivith 
TYielancholic  symptoms.  Chronic  melancholia. — Just 
as  we  saw  in  acute  melancholia  that  there  may  be 
active,  passive,  or  stupid  melancholy,  and  that  there 
may  be  melancholia  with  or  Avithout  delusions,  so  m 
considering  the  chronic  incurable  cases  it  is  note- 
worthy that  some  are  actively  melancholic  from  the 
beginning  to  the  end,  while  others  are  chronically 
passive.  This  was  marked  in  a  case  of  a  woman, 
forty-five  years  old,  admitted  into  Bethlem  in  con- 
sequence of  an  attempt  to  strangle  herself.  On 
admission  this  patient  moaned  aloud  and  wrung  her 
hands,  saying  she  had  destroyed  the  world.  She  was 
restless,  miserable,  solitary,  and  meagre.  She  con- 
tinued in  this  state  of  agitation  and  melancholy  not 
only  for  the  one  year  during  which  she  was  in  Bethlem, 
but  in  another  asylum  she  continues  up  to  the  present 
time  (eight  or  nine  years  having  elapsed)  still  to 
lament  in  the  same  strain  the  evils  she  is  causing. 
Such  a  case  is  all  but  hopeless,  and  although  the 
general  health  is  fair  and  the  appetite  improved  and 
sleep  better,  yet  the  prospect  of  mental  recovery  is 
extremely  small. 

Another  case  was  that  of  a  widow,  admitted  suf- 
fering with  melancholy  of  the  passive  type,  overbur- 
dened with  the  idea  that  her  un worthiness  had  caused 
the  death  of  her  husband  and  the  ruin  of  her  children, 
and  that  she,  an  unpardonable  sinner,  must  live  on  for 
ages  in  her  inhuman  and  unnatural  condition  ;  that 
nothing  could  save  her  from  the  living  hell  wliich  she 
was  now  experiencing.  Nothing  rouses  her  to  action, 
and,  unless  moved  by  the  attendants,  she  will  sit  from 
m^orning  to  night  alone  in  a  dark  corner  of  the  room- 
This  condition  of  passive  melancholia  may  last  for  years, 


230  Insanity  and  Allied  Neuroses.  [Chap.  ix. 

generally  ending  in  a  somewhat  more  placid  condition 
or  state  of  weak-mindedness,  but  often  with  no 
visibly  different  symptoms  occurring  for  many  years. 
Other  cases  (and  these,  perhaps,  the  more  commonly 
met  with  in  Bethlem)  are  those  suffering  from  recur- 
rent melancholia.  Thus,  a  widow  was  admitted 
to  the  incurable  list  of  Bethlem  in  1867,  having  had 
five  previous  attacks  of  melancholia  from  which  she 
had  recovered  :  she  had  had  a  hard  struggle  for  her 
existence,  in  consequence  of  the  state  of  her  mental 
health.  After  admission  she  was  desperately  de- 
pressed and  sleepless,  refusing  food,  and  insisting  on 
remaining  unoccupied  j  when  spoken  to,  she  replied  in 
a  whisper  that  she  must  be  left  to  her  fate,  and  that  it 
was  perfectly  useless  trying  to  do  anything  for  her ;  that 
she  was  altogether  a  wicked  person,  and  that  no  decent 
person  ought  to  speak  to  her  3  that  she  was  an  outcast 
and  can  never  be  well  or  good  again.  This  condition 
lasted  for  some  months,  then  slowly  passed  off,  leaving 
her  in  robust  health,  cheerful,  contented,  and  obliging. 
The  period  of  mental  soundness  continued  for  eighteen 
months,  and  then  a  cloud,  similar  to  previous  ones, 
settled  upon  her  with  the  same  symptoms.  During  the 
last  few  intervals  of  health  I  granted  her  a  free  pass 
to  go  in  and  out  of  the  hospital  at  will.  This  she 
always  used  properly,  and  when  she  felt  herself 
becoming  melancholic  she  declined  to  make  use  of  her 
freedom.  It  is  hard  to  believe  that  this  patient 
will  ever  remain  permanently  well ;  but  during  the 
past  few  years  the  attacks  of  mental  depression  have 
been  fewer  and  at  greater  intervals,  and  the  periods 
of  contentment  and  health  have  been  of  longer 
duration.  The  more  common  result  in  such  a  case  is, 
when  old  age  comes  on,  for  the  patient  to  be  more  un- 
stable, and  ultimately  to  become  more  weak  in  mind. 
In  Bethlem  we  have  on  the  incurable  list  a  fair 
number  of  such  cases,  who  from  their  education  and 


Chap.  IX.]  Permanent   Weak-mindedness.  231 

accomplishments,  while  they  ar©  iii  health  are  useful 
aids  towards  the  employment  and  amusement  of  the 
more  acute  cases. 

Recurrent  nielancliolia. — The  next  case  illustrates 
the  position  which  melancholia  may  take  in  a  case  of 
permanent  weak-mindedness,  Samuel  B.,  aged  thirty- 
five,  single,  a  stationer,  was  admitted  in  1853.  He  had 
suffered  from  one  previous  attack  of  insanity  ten  years 
before,  and  recovered.  After  a  period  of  depression  he 
became  excitable,  self-satisfied,  and  although  incapable 
of  being  trusted,  yet  he  was  easily  managed,  and  if 
not  interfered  with,  aided  in  work  about  the  hospital. 
He  was  subject,  at  irregular  intervals,  to  recur- 
rences of  depression,  in  which  he  refused  food,  and 
declined  to  speak.  This  stage  was  succeeded  by 
extreme  weakness.  He  had  to  be  fed  with  the 
stomach  pump,  and  notwithstanding  this  became 
much  emaciated.  He  slowly  recovered  from  the 
period  of  depression.  Attacks  of  this  kind  recurred, 
each  seeming  to  leave  him  weaker  in  mind,  so  that  he 
became  a  standing  joke  to  the  other  patients  on 
account  of  his  dandified  actions  and  gallant  airs. 
He  spent  his  time,  and  any  spare  money  he  be- 
came possessed  of,  in  additions  to  his  dress.  This 
condition  of  things  was  maintained  till  he  was 
sixty-three  years  of  age,  when  again  he  felt  sure 
he  was  unworthy.  He  was  fully  persuaded  that 
something  serious  was  going  to  happen,  and  that  he 
ought  not  to  eat.  He  declared  that  he  was  filled 
up,  and  that  there  was  no  more  room  for  food. 
Inflammation  of  the  right  lung  supervened,  and  he 
died.  Fost  morteyn  his  brain  was  found  to  be  of  fair 
weight,  dura  mater  normal,  excess  of  subarachnoid 
fluid,  membranes  free,  marked  depression  at  the  right 
apex  of  the  junction  of  the  first  frontal  with  first 
ascending  parietal  convolution.  There  were  some  signs 
of  softening  in  pons  varolii ;  the  rest  of  the  viscera, 


232  Insanity  and  Allied  Neuroses.  [Chap.  ix. 

except  the  lungs,  were  fairly  healthy.  This  case  is 
given  as  an  example  of  the  ordinary  end  of  a  case  of 
recurrent  melancholia. 

Recurrent  mania. — A  governess,  w^ho,  on  ad- 
mission into  Bethlem,  in  1866,  was  fifty-one  years  old, 
had  strongly  marked  insane  relationships  in  her  family, 
one  member  or  another  exhibiting  every  variety  of 
neurosis.  This  was  the  first  attack  of  insanity  re- 
quiring removal  to  an  asylum.  She  believed  that 
people  conspired  against  her,  and  periodically  she  had 
outbursts  of  extreme  excitement.  Each  attack  was, 
as  a  rule,  preceded  by  a  slight  period  of  hypochon- 
driacal depression,  and  at  the  same  time  there  was 
change  in  her  facial  aspect,  the  attendants  describing 
it  as  "  grinny  ;  "  and  I  think  "  sardonic  grin  "  very 
well  describes  the  expression.  For  many  years  this 
patient's  attacks  were  preceded  by  periods  of  mental 
health,  lasting  from  six  to  eight  weeks  at  a  time,  to 
be  followed  by  a  period  of  most  violent  and  destruc- 
tive mania.  Eor  instance,  in  one  particular  year  she 
became  excited  on  the  5th  of  January,  and  quiet  again 
on  the  13th  of  February  ;  then  excited  on  the  28th  of 
May,  and  quiet  once  more  on  the  16th  of  July.  In 
August  a  fresh  attack  of  excitement  was  followed  in 
September  by  quiet  \  in  October  again  excitement, 
followed  by  quiet  in  November,  and  in  the  middle  of 
November  a  fresh  attack  of  violence  occurred.  This, 
I  may  say,  was  a  year  of  exceptional  frequency  of  re- 
currence ;  but  some  years  would  pass  with  only  three 
attacks.  The  characteristic  of  the  attacks  was,  as  I 
have  said,  a  very  short  period  of  depression,  as  a  rule, 
but  sometimes  there  was  no  warning  whatever;  and 
I  have  known  this  patient  dine  quietly,  and  within 
five  minutes  of  the  conclusion  of  the  meal  be  as  de- 
structive and  violent  as  a  patient  could  be.  For  days 
she  would  scream,  threaten,  and  curse  in  the  most 
terrible  way,  almost  always  using  similar  expressions 


Chap.  IX.]  Recurrent  Mania.  233 

in  each  attack,  rhyming  time  after  time  on  hell  and 
devil ;  mistaking  her  relations  if  she  happened  to  see 
them,  and  imagining  that  those  who  were  dead  were 
still  about  her.  Night  brought  her  no  rest,  and 
for  weeks  together  this  excitement  would  rage.  Her 
appetite  was  large  and  food  was  taken  voraciously ; 
her  dress  was  disordered  and  torn,  and  her  grey 
hair  dishevelled  and  cast  to  the  winds.  No  special 
warning  heralded  the  cessation  of  the  storm,  but  as  it 
came  so  it  left,  sometimes  absolutely  suddenly,  the 
patient  being  weakened  and  exhausted  in  mind  and 
body  for  some  time  afterwards.  The  chief  peculiarity  of 
this  case  is,  that,  having  had  very  many  of  such  terrific 
nerve  storms  there  has  practically  been  no  intellectual 
degradation,  so  that  in  the  intervals  of  calm  this  lady's 
memory,  afi'ections,  and  habits  are  just  what  they 
might  have  been  without  this  recurrent  mania.  In 
my  opinion  this  depends,  to  a  great  extent,  upon  her 
strong  insane  inheritance.  As  for  treatment,  it  seems 
reasonable  to  try  the  effect  of  powerful  remedies,  such 
as  hyoscyamine  before  or  after  the  commencement  of 
each  outb.-eak  of  mania  ;  but  I  can  only  say  that  in 
this  case  I  gave  most  powerful  depressants  a.nd  nar- 
cotics  without  any  satisfactory  result.  For  a  time 
she  was  treated  with  hyoscyamine  \  but  the  effect  was 
that  the  excitement  was  ouly  temporarily  allayed, 
while  the  appetite  for  food  was  destroyed,  so  that  she 
became  alarmingly  weak.  For  two  years  I  kept  her 
almost  constantly  under  the  influence  of  conium  juice, 
giving  her  this  medicine  in  increasing  doses  up  to  four 
ounces,  and  I  was  inclined  to  believe  that  its  use 
seemed  to  be,  at  all  events,  associated  with  fewer  at- 
tacks, which  were  also  less  severe  ;  nor  was  any  damage 
done  to  her  general  health  or  appetite.  Whether  this 
was  the  result  of  years,  or  the  effect  of  the  medical 
treatment,  I  know  not,  but  this  patient  has  now  had 
more  than  twelve  months  of  quietness  and  sanity. 


2  34  Insanity  AND  Allied  Neuroses.  [Chap.  ix. 

Secondary  dementia^  lasting  unchanged  for  fifty 
years,  with  jjrogressive  wasthig  of  muscles. — Priscilla 
K.,  aged  77,  admitted  into  Bethlem  1832.  At  first 
she  was  mischievous,  with  jDeriods  of  depression  with 
refusal  of  food.  For  a  few  years  regular  attacks  of 
excitement  and  depression  occurred,  and  these  ended 
in  a  state  of  dementia.  The  patient  does  nothing  ; 
she  sits  alone,  but  with  a  pleased  smile  always  on 
her  face  ;  she  neither  speaks  to  nor  associates  with 
the  other  patients  ;  she  eats,  drinks,  and  sleeps.  She 
can  walk,  but  unless  forced  to  do  so  will  remain  where 
she  is  placed.  Every  now  and  then  she  makes  a 
chattering  noise,  and  seems  childishly  excited,  but  one 
cannot  trace  any  external  cause  for  this  excitement. 

Her  muscles  have  steadily  and  uniformly  wasted, 
till  her  hands  and  arms  look  like  a  skin-covered 
skeleton. 

This  patient  may  live  on  for  years,  unless  the 
chest  muscles  waste  too  much  to  continue  the  respira- 
tory function,  or  unless  she  meets  with  some  accident 
owing  to  her  feebleness. 

This  is  a  marked  example  of  progressive  removal  of 
higher  intellectual  centres,  which  being  so  gradual  has 
allowed  accommodation.  A  more  rapid  process  must 
have  killed  the  patient  long  ago. 

Weak-mindedness  with  persistence  of  one  or  more 
morbid  ideas  is  also  common,  and  this  group  of  cases 
leads  very  naturally  to  that  in  which  we  find  patients 
with  fixed  delusions  as  of  persecution,  and  others  with 
monomaniacal  ideas. 

One  lady,  who  has  been  over  twenty  years  in 
Bethlem,  is  always  quiet  and  well  behaved ;  she  shuns 
notice,  and  often  students  spend  six  months  in  the 
hospital  without  seeing  her.  She  is  possessed  by  the 
idea  that  Methuselah  is  coming  for  her,  and  so, 
regardless  of  other  men,  she  guards  her  fading  charms 
for  this  father  of  mankind. 


Chap.  IX.]  Chronic  Insanity.  235 

Chronic  insanity  with  hyjjochoiidriacal  delusions. 
— Jane  J.,  single,  67,  governess;  first  attack  of  in- 
sanity was  in  1852.  Several  other  attacks  followed, 
and  at  length,  in  1857,  she  was  placed  on  the  in- 
curable establishment  of  Bethlem. 

She  had  melancholic  ideas  at  one  time,  and  was 
excited  and  maniacal  at  others;  she  believed  the 
doctors  and  others  were  injuring  her,  and  she  com- 
plained of  a  feeling  of  confusion,  her  chief  cry  being  to 
be  "let  alone  and  not  bothered."  She  fancied  things 
were  done  to  annoy  her,  and  that  even  the  birds 
sang  only  to  tease  her. 

At  irregular  intervals  attacks  of  the  above  kind 
came  on  and  passed  away,  leaving  the  lady  again  busy 
and  pleasant.  She  was  very  handy  with  pen,  pencil, 
and  needle,  and  spent  her  time  in  writing  a  novel, 
drawing  flowers,  or  doing  fancy  work ;  but  during  the 
periods  of  quiet  she  is  fully  possessed  by  the  idea  that 
she  is  making  new  lungs,  and  attendants  object  to 
go  out  into  the  streets  with  her  because  of  a  blow- 
ing noise  she  makes  every  few  minutes,  regardless  of 
her  surroundings. 

At  times  she  spends  whole  days  and  nights  making 
distressing  noises.  It  is  interesting  to  note  that 
this  patient  suffers  from  emphysema  of  the  lungs.  She 
is  full  of  hope  still  of  marrying.  She  will  remain  as 
she  is  probably  to  extreme  old  age. 

Another  lady  who  suffered  from  melancholia  of 
the  most  profound  kind  for  years  passed  into  a  state 
of  partial  weak-mindedness,  which  has  long  been  little 
more  than  hypochondriasis.  Her  one  object  in  life 
is  to  think  of  her  ailments  and  of  her  misfortunes. 
Her  letters  are  full  of  references  to  the  buried  past, 
and  are  of  a  childish  character.  Acute  melancholia 
has  changed  the  once  active  but  emotionally  religious 
woman  into  a  confirmed  hypochondriac,  fit  only  for 
an  asylum. 


236  Insanity  and  Allied  Neuroses.  [Chap.  ix. 

A  similar  case  was  that  of  a  man  already  referred 
to,  whose  one  idea  was  his  coming  meal,  and  his  one 
expression  was  the  character  of  that  meal.  He  would 
thus  in  the  morning  from  breakfast  to  dinner  time 
say  once  a  minute,  "  I  will  have  my  dinner  at  one 
o'clock."     He  died  at  the  age  of  78. 

Among  cases  of  chronic  insanity  are  placed  those 
having  more  or  less  complete  loss  of  mental  power ; 
this  may  be  exhibited  by  loss  of  control,  by  sensory 
defect,  by  want  of  will-power  or  of  memory,  with 
survival  of  some  human  attributes.  It  may  be 
characterised  by  insane  habit,  as  when  mania  or 
melancholia  become  chronic.  It  may  be  marked  by 
instability,  so  that  there  are  periodical  outbreaks  or 
tendencies  to  be  easily  upset.  It  may  be  shown  by 
the  growth  or  persistence  of  delusions  of  any  kind. 

As  far  as  treatment  is  concerned,  nothing  can  be 
added  beyond  what  I  said  about  cases  of  dementia. 

Prognosis. — Though  it  is  generally  accepted 
that  insanity  which  has  lasted  for  a  few  years,  and 
insanity  which  has  not  changed  during  that  time,  is 
not  likely  to  be  recovered  from,  yet  cures  occur  from 
time  to  time  among  the  most  chronic  cases.  In  some 
cases,  especially  among  women  between  forty  and  fifty 
years  of  age,  a  fresh  vital  balance  is  established,  and 
with  this  there  may,  after  years  of  alienation,  be  a 
return  to  sanity.  In  others,  patients  grow  into  cer- 
tain habits,  and  unless  removed  they  will  remain 
till  the  end  of  their  days  placidly  weak-minded. 

I  believe  that  removal  from  one  asylum  to  another 
would  be  of  great  service  in  some  cases ;  just  as  the 
bone-setter  from  time  to  time  performs  some  extra- 
ordinary cure  by  breaking  down  adhesions  round  a 
joint,  so  the  change  to  less  agreeable  surroundings  may 
set  free  the  latent  powers  of  the  mind. 


237 


CHAPTER   X. 

DELUSIONAL    INSANITY — HALLUCINATIONS. 

Examples  of  insanity  depending  on  hallucinations — Delusional 
insanity  in  man,  persecution,  etc. — Delusional  insanity  in 
woman,  persecution,  etc. — Delusional  insanity  in  woman, 
exaltation — Delusional  insanity  with  jealousy — Delusional 
insanity  with  ideas  of  constant  change  in  the  surroundings— 
"  Symbolisms." 

Chronic  insamty  associated  with  halluci- 
nations and  delusions.    Delusional  insanity. 

— In  this  group  of  cases  I  shall  have  to  describe  a 
class  of  patients  who  have  generally  been  placed  with 
those  suffering  from  mental  weakness ;  but  there  seem 
to  be  several  objections  to  this,  the  chief  one  being 
that,  except  from  an  expert's  point  of  view,  these 
patients  are  often  extremely  shrewd,  and  exhibit  none 
of  the  ordinary  symptoms  of  weak-mindedness,  their 
memories  being  good,  their  volition  strong,  and  their 
emotions  well  under  control.  They  differ  from  those 
whom  we  call  sane  in  having  sense  impressions,  which 
differ  entirely  from  the  sense  impressions  of  the 
ordinary  person,  or  in  having  some  fixed  idea,  which 
owes  its  origin  to  some  sensation  and  feeling  which 
we  do  not  understand  ;  and  this  delusion,  like  the 
hypochondriac's  sensation,  is  not  to  be  removed  by 
argument.  Such  persons  have  a  faculty  of  faith ; 
"they  cannot  reason,  they  can  only  feel."  Any  one 
of  the  senses  may  mislead  the  mind,  and  any  false 
idea  may  become  fixed ;  but  the  interest  in  these  cases 
lies  in  the  fact  that  though  so  many  possible  com- 
binations of  symptoms  might  occur,  practically  the 
groupings  are  few  and  definite  in  character. 


238 


Insanity  and  Allied  Neuroses.    [Chap.  x. 


In  most  cases  these  ideas  have  a  direct  relationship 
to  the  preservation  of  the  individual  or  to  the  exis- 
tence of  society.  They  belong  to  his  social  side. 
Suspicion,  jealousy,  and  the  like,  represent  the 
character  of  the  delusion. 

I   am    quite  unable  here  to  fully  enter  into   the 


A  case  of  Dalasional  Insanity  with  Hallucinations  of  Hearing. 

development  of  hallucinations  ;  but  I  sliall  take  this 
opportunity  of  briefly  referring  to  some  of  the  chief 
varieties,  and  I  shall  take  occasion  to  illustrate  them 
by  typical  exampl3s. 

Hallucinations  may  be  described  as  sense-im- 
pressions resulting  without  any  external  stimulus,  so 
that  hallucinations  of  sight  may  occur  in  darkness  or 
to  blind  eyes  ;  and  hallucinations  of  hearing  are  to  be 


Chap.  X.]  Delusional  Insanity.  239 

met  with  not  uncommonly  among  deaf  j)atients  as  well 
as  in  the  stillness  of  night.  Hallucinations  may  occur 
in  any  one  of  the  senses  ;  they  may  occur  in  one  of 
"OnQ  bi-lateral  senses,  so  that  one  ear  alone  may  be 
subject  to  hallucinations.  Hallucinations  may  occur 
in  various  forms  of  mental  disorder ;  hallucinations 
of  sight  being  very  common  in  some  of  the  more 
acute  cases  of  mania  as  well  as  in  delirium.  In  fact, 
hallucinations  of  all  the  senses  may  occur  in  mania 
similar  to  those  met  with  in  delirium.  Hallucinations 
of  hearing  are  the  most  common,  "  voices "  being 
most  frequently  met  with  ;  the  voices  may  speak  in  a 
whisper  at  a  distance,  may  speak  directly  into  the 
ear,  or  may  shout  loudly,  or  even  scream.  They  may 
be  heard  from  above  or  from  below,  in  the  chimney 
or  under  the  floor.  The  "  voice  "  may  apjDear  as  that 
of  a  man  or  woman ;  it  may  be  recognised  as  friendly 
or  inimical ;  it  may  appear  to  be  in  a  monotone,  or  it 
may  appear  as  a  chant.  Besides  "  voices,"  the  patients 
may  hear  buzzings  or  thum  pings  as  of  a  hammer, 
or  of  a  drag  on  a  carriage,  or  there  may  be  whistlings, 
growlings,  or,  what  is  comparatively  common,  ringing 
of  bells,  or  the  knocking  of  nails  in  a  supposed  coffin. 
A  medical  friend  of  mine  suffered  for  some  time  with 
hallucinations  of  hearing,  which  at  one  period  caused 
him  to  discharge  his  coachman  because  he  believed  he 
was  always  using  the  drag  on  the  wheel,  and  later  he 
was  constantly  annoyed  by  what  he  believed  to  be 
run-away  rings  at  his  night-bell.  I  would  say  that, 
as  a  rule,  hallucinations  with  recovery  become  fainter 
and  fainter  as  if  a  distance  were  being  placed  between 
them  and  the  hearer.  It  does  not  follow  that  persons 
having  hallucinations  should  necessarily  be  of  unsound 
mind,  but  there  are  two  conditions  in  which  their  pre- 
sence is  of  great  consequence.  In  a  patient  predisposed 
to  insanity  by  inheritance,  or  one  who  has  had  previous 
attacks,  any  recurrence  of  hallucinations  should  render 


2  40         Insanity  AND  Allied  Neuroses,   [Cimp.  x. 

the  Mends  on  tlieir  guard  and  cause  extra  caution. 
And  again,  if  a  patient  has  suiFered  from  insanity,  in 
which  hallucinations  have  been  prominent  symptoms, 
it  is  well  not  to  discharge  him  finally  as  recovered  till 
all  hallucinations  have  passed  away.  I  have  known 
one  patient  in  Bethlem,  who  told  me  that  for  months 
before  it  was  necessary  for  her  to  be  sent  from  home, 
she  heard  voices  up  the  chimney,  and  that  she  treated 
them  exactly  as  she  would  wandering  thoughts  when 
reading  a  book,  by  an  involuntary  shake  of  the  head, 
and  a  fresh  application  to  the  work  in  hand ;  but,  as 
she  lost  physical  strength,  she  found  this  impossible, 
and  in  the  end  the  voices  controlled  her,  and  not  she 
the  voices. 

In  another  case,  the  patient,  who  had  suffered  from 
profound  melancholia  with  ideas  that  she  was  ruined 
and  must  go  to  the  workhouse,  having  lost  these 
melancholic  ideas,  yet  told  me  that  when  reading  to 
herself,  or  thinking,  everything  she  either  read  and 
comprehended  or  that  she  thought  carefully  about 
was  repeated  in  a  peculiar  musical  way  two  feet 
above  her  head.  Hallucinations  of  hearing,  then,  may 
be  associated  with  various  forms  of  insanity.  As  a 
rule,  they  are  painful  impressions  ;  but  I  had  for- 
merly in  Bethlem  a  patient  who  enjoyed,  as  he 
said,  his  conversations  with  a  French  lady  who  went 
for  walks  with  him.  In  this  case  hallucinations  of 
hearing  were  associated  with  other  hallucinations, 
and  when  he  enjoyed  those  pleasant  hallucinations  of 
hearing  he  also  perceived  a  pleasant  odour ;  but 
when,  later  in  his  disorder,  he  suffered  from  two 
voices  wrangling  with  him,  the  querulous  and  oppos- 
ing voice  was  associated  with  a  disagreeable  smell. 
In  this  case  the  patient  finally  developed  the  idea 
that  he  had  a  spiritual  wife  within  him  who  com- 
muned constantly  with  him,  and  who  had  prophetic, 
spiritualistic,  and  mesmeric  powers. 


Chap.  X.]  Thought-Re ADiNG.  241 

The  next  point  for  consideration  in  respect  to 
hallucinations  of  hearing  is  the  power  which  patients 
suppose  to  be  possessed  by  others  of  reading  their 
thoughts.  There  are  always  patients  whose  chief  com- 
plaint is  that  persons  know  their  thoughts,  or  know 
more  about  them  than  they  ought ;  they  seem  to 
be  unduly  sensitive,  as  it  were,  to  their  neighbours. 
Such  patients  may  say  they  have  "  loud  thoughts," 
and  they  will  avoid  every  contact  with  others  for 
fear  that  their  inner  life  may  be  known.  Re- 
cently there  was  a  man  in  Bethlem  who  would 
not  allow  any  one  to  sit  within  earshot  of  him, 
if  he  could  help  it.  Another  patient  was  admitted 
because  he  had  committed  assaults  upon  people 
for  no  other  reason  than  that  they  knew  too  much 
about  him.  This  patient  used  to  go  early  in  the 
morning  on  the  top  of  a  hillock  on  Hampstead 
Heath,  to  keep  a  look  out  that  no  one  was  observing 
him  or  taking  his  thoughts  away  from  him.  Another 
patient  found  that  his  thoughts  were  heard  by  some 
means,  and  were  also  answered  ;  questions  were  con- 
stantly put  to  him  by  day  and  night,  in  the  gallery, 
the  airing-court,  at  the  closet,  and  even  at  chapel ; 
various  taunts  and  insinuations  w^ere  conveyed  to 
him  in  this  manner.  He  insisted  that  these  voices 
came  through  a  telephone  ;  he  thought  that  with  the 
microphone  and  telephone  the  slightest  sound  could  be 
made  audible.  He  was  told  by  a  voice  one  night 
that  it  was  due  to  the  pulsation  of  the  brain,  but  he 
thought  it  might  also  be  from  the  imperceptible  action 
of  his  own  organs  of  speech,  for  he  finds  that  when  he 
thinks  vehemently  the  tongue  moves  slightly.  The 
way  these  feelings  are  interpreted  is  endless ;  one 
patient  was  very  angry  with  me  because  he  be- 
lieved that  I  kept  by  me  a  most  marvellous  set  of 
microphones  and  telephones  which  enabled  me  to 
follow  the  thoughts  of  each  patient  at  will.  With 
Q— 14 


242  Insanity  and  Allied  Neuroses.    [Chap.  x. 

the  development  of  any  new  instrument  which  be- 
comes popularly  known,  there  is  always  a  free  use 
of  the  discovery  made  by  the  insane  ;  and  in  Bethlem 
we  hear  of  every  variety  of  telephonic  communica- 
tion. 

Hallucinations  of  sight  are  not  so  common  as 
hallucinations  of  hearing  ;  they  are  met  with  in  con- 
ditions allied  to  delirium,  and  in  acute  delirious  mania 
patients  see  all  sorts  of  moving  bodies.  In  a  few 
cases  of  mania  there  are  visions  of  horror ;  and,  asso- 
ciated with  religious  melancholia,  visions  of  hell,  of 
angels,  of  threatening  spirits,  and  the  like,  are  seen. 
In  many  cases,  especially  when  ideas  of  persecution 
exist,  dead  friends  are  seen,  and  some  chronic  lunatics 
thus  appear  to  be  spiritualists.  Occasionally  associated 
with  hallucinations  of  sight  ideas  of  filthiness  or  con- 
tagiousness are  met  with,  and  especially  those  patients 
who  believe  they  have  the  itch  will,  at  the  same  time, 
often  declare  themselves  to  be  filthy.  In  one  or  two 
cases  I  have  met  with  hallucinations  of  sight,  which 
seemed  to  be  but  the  misinterpretation  of  imtscm  voli- 
tantes.  One  lady  was  constantly  shaking  her  handker- 
chief in  front  of  her  face,  rubbing  her  hands  on  parts 
of  her  dress,  and  then,  unless  prevented,  would  throw 
the  handkerchief  into  the  fire,  believing  it  was  covered 
with  vermin.  Her  description  of  the  upward  and 
downward  movements  of  the  vermin  corresponded  to 
the  ordinary  movements  of  muscce  volitantes,  A  num- 
ber of  patients  suffering  from  chronic  insanity,  who  be- 
lieve themselves  to  be  watched,  persecuted,  or  otherwise 
influenced  from  without,  think  that  certain  "  phan- 
tasmagoria," as  they  call  them,  are  played  before  them 
at  night  to  alarm  or  injure  them.  Occasionally,  but 
rarely,  the  patient  may  be  induced  to  draw  his  ideas 
of  what  he  sees  ;  but  I  have  never  been  able  to  get  a 
satisfactory,  or,  in  fact,  comprehensible  vision  repre- 
sented by  an  insane  person. 


Chap.  X.]        Hallucinations  of  Smell.  243 

Tlie  other  senses  are  less  highly  developed,  and 
the  exhibition  of  disorder  in  their  action  is  less 
marked  and  varied 

With  taste  we  get  hallucinations,  or,  more  com- 
monly still,  illusions  associated  with  ideas  of  poison, 
In  many  cases,  young  women  with  ovarian  distur- 
bances, and,  perhaps,  sickness,  refuse  food,  complaining 
of  bad  smells  and  tastes  of  poison.  I  have  seen  the 
same  refusal  of  food  due  to  the  same  hallucinations 
in  a  woman  who  had  had  children,  and  was  therefore 
used  to  the  vomiting  of  pregnancy;  yet  when  insane 
she  explained  her  sickness  as  due  to  metallic  poisoning. 
In  phthisis,  again,  patients  frequently  refuse  their 
food,  believing  they  are  being  poisoned.  Insane 
patients  may  complain  of  poisoning,  or  of  acid  tastes 
allied  to  that  produced  by  electricity,  but  very  com- 
monly the  complaint  is  either  that  drugs  are  put  into 
the  food,  with  the  intention  of  producing  insanity 
or  insensibility,  or  that  filth  of  some  kind,  most 
commonly  faecal,  is  administered  with  drink  or  meat. 
Others  fancy  human  flesh  or  blood  are  given  them. 
Some  patients  say  that  all  power  of  discrimination 
has  been  lost,  and  that  their  taste,  in  fact,  has  been 
taken  away.  Hallucinations  of  taste  may  occur  with 
ordinary  mania,  but  are  more  common  in  melancholia 
and  in  conditions  of  weak-mindedness. 

The  hallucinations  of  smell  are  very  similar  to 
those  of  taste.  Occasionally,  in  the  excitement  of 
mania  and  of  general  paralysis,  there  are  pleasant 
hallucinations  of  smell ;  but  in  many  cases  of  mental 
depression^  especially  those  associated  with  ovarian 
and  uterine  trouble,  the  smells  are  of  an  unpleasant 
kind :  one  woman  complaining  of  dead  bodies  near 
her,  while  another  thinks  a  smell  of  dung  pervades  the 
room,  or  emanates  from  her  own  body,  A  few  com- 
plain of  a  pungent  odour  like  that  of  ammonia,  and 
certain  "  miserable  sinners "  complain  of  a  foretaste- 


244         Insanity  and  Allied  Neuroses.    [Chap.  x. 

of  hell  in  the  shape  of  smells  of  brimstone.  It 
has  been  said  that  in  general  paralysis  the  patient 
early  loses  the  power  of  discriminating  the  smell  of 
pepper,  but  in  my  experience  this  is  not  at  all  a 
common  defect  in  such  cases. 

The  last  point  to  consider  here  is  common  sen- 
sibility, and  its  endless  perversions.  Patients,  espe- 
cially at  the  climacteric,  are  in  the  habit  of  com- 
plaining that  they  are  badly  treated  ;  that,  in  fact, 
persons  take  liberties  with  them,  and  they  will 
describe  hideous  tortures  to  which  they  are  subjected. 
Some  will  accuse  nurses  and  doctors  of  chloroforming 
them,  of  burning  them  during  the  night  with  acid, 
chloride  of  lime,  or  ammonia.  The  most  common 
complaint,  however,  is  that  electricity,  magnetism, 
galvanism,  mesmerism,  or  some  other  subtle  force  is 
brought  to  bear  upon  them,  and  applied  to  torment 
them  by  their  enemies. 

A  patient^ s  descri2)tion  of  his  hallucinations,  taken 
down  by  the  head  attendant.  Mesmeric  influence. 
"  (I  must  see  the  Telephone  Company  with  a  view 
of  learning  the  most  recent  investigations).  My  de- 
ductions since  being  here,  from  experiences  in  general, 
are  as  follows  : 

"  I  have  heard  the  same  set  of  three  voices,  in- 
cluding a  female,  with  occasionally  a  third  or  fourth 
at  intervals  ;  these  voices  are  those  of  my  neighbour, 
J.  B.,  of  New  Cross,  and  his  wife  ;  the  voices  have 
travelled  with  me  for  some  eight  miles  from  home ; 
I  have  heard  them  make  remarkably  intelligent 
observations,  always  at  the  time  of  speaking  accom- 
panied by  electrical  vibrations  or  slight  shocks,  the 
farther  away  from  the  first  starting-point  the  less 
disagreeable ;  they  have  used  strong  words  as  to 
business  affairs  which  were  being  carried  on  at  the 
time.  They  anticipate  my  words  before  they  are 
spoken  (this  occurrence  has  only  been  noticed  during 


chap.x.]  Voice  Hallucinations.  245 

the  last  three  weeks).  If  I  begin  by  uttering  a 
sentence^  and  by  effort  abruptly  check  the  thought, 
which  is  an  exceedingly  difficult  matter,  they  make  an 
observation ;  they  can  see  me  wherever  I  may  be,  or 
wherever  the  current  is  carried,  by,  I  presume,  the  aid 
of  two  glasses  ;  and  have  also  from  remarks  made  a 
figure  of  the  human  body,  with  its  anatomical  arrange- 
ment, so  as  to  enable  them  to  pass  the  current  to  any 
part  of  my  body  and  receive  the  reflex  ;  they  can  see 
by  the  figure's  parts  how  such  and  such  directed 
shocks  emanating  from  the  operator  take  effect, 
showing  with  what  success  the  shot  has  succeeded. 
For  example  :  many  times  when  I  have  taken  a  seat 
a  remark  has  been  made  such  as  this  :  '  We'll  give  his 
heart  a  touch  ! '  Another  voice  asks,  '  Which  side  is 
his  heart  % '  The  shock  or  shocks  have  been  given  on 
receiving  the  answer  like  the  pricking  of  a  pin,  three  or 
four  generally.  This  is  not  particularly  disagreeable, 
until  it  is  repeated  ;  then  a  remark  is  again  made  as 
to  the  pulsation.  This  generally  is  accompanied  with 
a  slight  vibration  under  my  feet,  and  through  the 
chair  to  my  body.  At  other  times  it  catches  my 
thighs  particularly,  drawing  me,  as  it  were,  downwards, 
always  accompanied  by  some  exceedingly  disagreeable 
observations,  in  the  gallery  and  elsewhere  :  '  There, 
now  look  at  the  him  ;  he  can't  stand.  Look  at  him  ! ' 
It  takes  all  my  effort  to  stand  upright,  by  straining 
my  muscles  and  withdrawing  the  strain  again.  This 
applies  to  particular  parts  of  the  carpet,  and  is  not  con- 
fined to  the  same  parts,  but  varies  as  the  operator 
says,  '  Now  give  it  him  hot ! '  when  I  hear  the  bat- 
tery working,  and  thirty  seconds  or  so  after  comes  the 
tingling  sensation  on  the  spot,  which  is  continued  for 
about  thirty  paces  (I  hear  the  wife  saying,  '  Try  to  get 
over  them  !  ')  and  if  I  stand  produces  the  tension 
of  my  body,  which  would,  without  great  effort  on  my 
part,  compel  me  to  fall.     This  applies  to  wherever  I 


246  Insanity  and  Allied  Neuroses.    [Chap.  x. 

may  be  walking.  I  find  these  influences  show  them- 
selves more  decidedly  when  I  wear  boots  with 
nails  in  the  soles  and  heels,  and  particularly  when 
walking  between  two  iron  gratings  or  other  iron  sub- 
stances, or  between  two  looking-glasses.  I  have  dis- 
covered that  walking  at  right  angles  saves  me  from 
getting  a  disagreeable  jerking  of  my  muscles,  in  com- 
parison with  turning  a  curve.  The  peculiar  electrical 
influences  when  walking  seem  to  be  regulated  at  the 
operator's  will.  As  regards  the  alteration  of  the  spot, 
I  always  find  (when  I  am  sitting)  about  my  head  and 
neck  a  drawing  sensation  towards  the  window,  espe- 
cially between  the  shoulders  ;  this  I  put  down  to  the 
window  frames  being  made  of  iron,  which  I  have  only 
lately  discovered,  as  also  the  walking  between  the  iron 
gratings.  When  at  my  meals  the  voices  make  remarks 
about  my  eating,  and  the  way  I  use  my  knife  and 
fork,  etc.  Sometimes  I  see  in  the  room,  like  a  flash 
across  my  face  or  by  the  side  of  my  head,  what  appears 
like  a  fused  length  of  silk  about  eighteen  inches  long, 
which  for  the  moment  gives  me  a  shock  very  sud- 
denly, accompanied  by  terrible  threats  from  the  same 
voices  at  intervals.      While  I  have  been   out  in  the 

gallery  during  Mr.  D 's   (the  attendant)  absence, 

the  carpet  has  been  exceedingly  strongly  charged, 
quite  disabling  me  from  standing  still  \  the  only  means 
of  saving  myself  from  falling  being  to  alternate  my 
steps,  and  step  from  right  to  left.  The  carpet  retains 
the  electricity  for  a  very  short  space  of  time,  this  being 
accompanied    with    such    venomous    remarks    as    the 

following  :   "Oh,  you  ■ ■  W.,  my  bowels  are  waiting 

patiently  for  you  to-night !  '  The  female  voice  bears 
all  possible  resemblance  to  that  of  Mrs.  F.,  whom  I 
know  but  very  little  of,  but  sufiicient  to  recognise  her 
voice.  All  throughout  in  her  manner  she  has  shown 
decided  symptoms  of  hysteria,  frequently  crying  out, 
'  Oh,  Mr.  W.  !  Mr.  W. !  what  will  become  of  your  dear 


Chap.  X.]  Voice  Hallucinations.  247 

wife  and  cliildren  % '  and  then  shortly  afterwards  re- 
marks diametrically  opposite.  At  other  times  she 
speaks  in  the  ordinary  rational  way.  The  remarks 
from  all  four  voices,  or,  possibly,  five,  are  heard 
throughout,  as  though  it  were  through  an  aperture  or 
speaking-tube. 

"In  the  atmosphere  the  prominent  striking  features 
that  occur  throughout  the  day  are  (1)  as  though 
a  pellet  something  like  a  quid  of  tobacco  was  sent 
across  the  room  with  force  against  the  wall  or  other 
object,  apparently  connected  with  the  thread,  as  I 
have  seen  it  occasionally  partly  in  fusion  (the 
voices  are  now  saying,  '  D — - —  him ;  we  will  have 
him  off  to-night ! '),  with  a  thud-like  sound,  have  seen 
it  strike  a  piece  of  newspaper  on  the  couch,  and  move 
it  (I  possibly  fancy  this  motion).  As  soon  as  the  con- 
cussion is  produced,  there  emanate  from  it  a  large 
number  of  these  gossamer  threads,  known  by  their 
creeping  sensation  upon  different  parts  of  the  body, 
each  charged  with  electricity,  from  the  tingling  sensa- 
tion they  produce,  settling  upon  the  clothes,  and 
finding  their  way  to  the  body  by  way  of  the  neck- 
collar,  wrist-bands,  etc.  ;  (2)  I  have  found,  without 
exception,  across  all  prominent  doorways  leading  from 
the  house  one  of  these  threads,  which  catch  the  neck 
or  face,  and  produce  the  same  tingling  sensation,  which 
does  not  leave  me  throughout  the  day. 

"I  suppose  that  these  threads  are  in  connection 
with  the  battery,  which,  being  of  so  delicate  a  sub- 
stance, seems  not  to  break  but  rather  give  ;  or  it  may 
be,  if  it  breaks,  there  is  so  strong  an  affinity  to  the  two 
broken  parts  that  they  readily  join  again;  such  being 
the  case  would  account  for  the  medium  being  carried 
to  an  almost  infinite  distance. 

"  Second  kind  of  discharge  is  like  a  sudden  prick 
through  the  coat,  aimed  at  a  certain  spot  as  spoken 
of  by  the  operator,  who  appears  taken  off  his  guard, 


248         Insanity  and  Allied  Neuroses.    [Chap.  x. 

talking  too  loudly ;  the  pricking  or  smarting  comes 
direct  to  the  spot  (the  pricking  more  frequent). 

"  Third  kind,  only  heard  in  the  bedroom  at  night. 
This  is  preceded  by  an  extra  violent  exercising  of  the 
battery,  result  being  a  loud  noise,  always  the  same, 
resembling  an  iron  plate  being  struck  with  a  hammer, 
or  a  ball  from  Shoeburyness  striking  the  butt  or 
target ;  result,  vibration  in  different  parts  of  the  bed, 
producing  internal  convulsive  feelings,  rising  from  the 
abdomen  in  spasms  (not  particularly  painful,  like 
wind),  w^hich  rise  to  the  region  of  the  heart.  Pre- 
vious to  the  operator's  performance,  the  question 
has  been  asked:  'Which  side  does  W.  lie?'  An- 
swer :  '  On  his  right ' ;  sometimes,  '  Oh  !  I  don't 
know '  (the  voices  are  again  speaking,  saying  :  '  Now, 

you  ,  you  will  not  get  out ;    we  have  got  you  !) ; 

when  the  object  which  sounds  like  a  broken  plate 
(but  of  course  is  not  one)  at  the  time  of  concussion, 
there  seems  to  radiate  from  it  several  of  the  before- 
mentioned  pellets,  as  they  appear  to  drop  on  the  bed, 
the  pillow  more  frequently,  only  smaller  than  the 
pellets  on  the  wall,  making  but  a  slight  sound,  and 
they  seem  singly  to  be  inhaled,  accompanied  by  a 
dryness  of  the  thorax,  as  of  thirst.  Sensation  :  a 
strong  feeling  of  faintness  and  desire  to  go  to  sleep, 
with  the  constant  lulling  sound,  '  Go  to  sleep  !  go  to 
sleep ! '   which    was   accompanied    with   the   repeated 

remarks :    '  I   wish  the    ,'    or    some  other 

epithet,  '  would  go  to  sleep.  Lor'  bless  you !  his 
heart  is  almost  stopped  now.'  I  keep  as  quiet  as 
possible.  Another  remark  comes  in  a  whisper  :  '  It's 
all  up  with  him,  I  think.'  This  has  occurred  on 
about  five  occasions,  in  such  a  way  as  to  produce  a 
feeling  of  extreme  exhaustion ;  and  on  rising  in  the 
morning,  after  hearing  throughout  the  night  plainly- 
spoken  remarks,  with  oaths,  '  He  shan't  leave  the 
bedroom  to-night  alive/  the  feeling  has  worn  off  to  a 


Chap.  X.]  "  Sexual   Vampires^  249 

great  extent  towards  morning,  when  I  have  been  able 
to  get  out  of  bed  much  to  their  expressed  surprise. 

"I  believe  (this  I  say  with  all  solemnity)  I  should 
have  succumbed  on  three  occasions  had  it  not  been  for 
feigning  sleep,  or  from  the  operator  (of  which  there 
are  two  or  three  engaged)  giving  in  towards  the 
last,  with  the  remark,  when  told  to  set  it  on  more 
strongly  :  '  I  can't,  and  I  won't,  do  the  murderous 
job  ;  let  it  stand  till  five  o'clock  in  the  morning.' 

"  Felt  the  tingling  sensation  about  seven  months 
ago,  but  at  first  did  not  pay  much  attention. 

"  The  voices  were  here  prominently  about  four 
months  ago,  when  I  began  to  get  alarmed,  as  they 
were  accompanied  by  exceedingly  offensive  epithets, 
and  from  ten  weeks  back  by  threats. 

"  During  this  morning,  in  the  grounds^  a  curious 
remark  was  made  :   'It  shall  be  his  children  next.'  " 

When  referring  to  hallucinations  of  sight,  I  said 
that  other  hallucinations  were  frequently  associated 
with  them,  and  that  a  feeling  of  being  dirty  or  filthy 
was  not  a  rare  accompaniment  of  visual  hallucination. 
Some  years  ago  we  had  at  one  time  several  cases  of 
elderly  spinsters  in  Bethlem,  who  had  probably  spent 
a  great  part  of  their  lives  in  tidying  and  dusting 
the  relics  which  they  kept  in  their  prim  little  houses  ; 
dust  and  dirt  were  their  abominations,  and  when  they 
became  insane  they  naturally  developed  from  their 
uneasy  feelings  an  idea  that  everything  about  them 
was  filthy.  In  this  case  the  quiet  and  discipline  of 
an  asylum  enabled  them  to  return  once  more  to  their 
old-maidish  habits. 

Galvanism  is  made  use  of  very  frequently  to 
explain  almost  every  morbid  sensation  which  a 
patient  experiences.  Another  class  of  feelings  re- 
lating to  these  must  be  alluded  to  here.  A  certain 
number  of  men,  generally  of  young  middle  age, 
become   possessed   by  the   idea   that  they  are  being 


250  Insanity  AND  Allied  Neuroses.    [Chap.  x. 

weakened  by  some  process  by  which  their  virility 
is  drawn  off;  and,  just  as  I  previously  said  that 
no  class  of  patients  is  more  suicidally  inclined 
than  those  who  believe  themselves  to  be  impotent, 
so  none  are  more  dangerous  than  those  who  believe 
themselves  to  be  "  tapped,"  "  drawn,"  or  "  emascu- 
lated "  by  others.  A  patient  recently  in  Bethlem, 
who  had  lost  the  sight  of  one  eye,  and  who  had  been 
under  the  surgical  care  of  a  leading  London  oculist, 
became  possessed  by  the  idea  that  this  oculist  was 
able  to  weaken  him  by  the  removal  of  his  semen ;  the 
consequence  was  that  he  was  most  murderously  in- 
clined, not  only  towards  the  oculist,  but  to  all  in  any 
way  connected  or  acquainted  with  him. 

In  another  somewhat  similar  case,  an  older  man, 
of  very  insane  family,  was  impressed  by  the  idea  that 
there  was  a  kind  of  society,  the  function  of  which  was 
to  "draw"  men,  as  he  called  it.  He  seemed  to  look 
upon  them  as  sexual  vampires.  He  thought  that  the 
owner  of  a  large  private  asylum  had  a  staff  of 
"  runners,"  who  pursued,  debauched,  and  emasculated 
those  who  had  been  placed  at  any  time  under  his 
medical  care.  This  patient  being  influenced  by  this 
idea  was  found,  when  at  large,  with  a  dangerous- 
looking  knife  in  search  of  "  runners  ; "  and  I  have  no 
doubt  would  have  made  an  end  of  any  one  he  took  to 
be  such.  In  the  end  he  was  declared  to  be  a  lunatic, 
and  was  placed  under  the  charge  of  the  Lord  Chan- 
cellor. I  may  say  his  delusion  affected  not  only  his 
ideas  about  himself,  but  also  about  others,  and  when 
addressing  the  special  jury  he  told  them  that  they,  as 
honest  men,  knew  that  half  of  them  were  eunuchs. 

So  far,  then,  for  the  special  relationship  of 
hallucinations.  After  thus  describing  them,  it  will 
be  only  necessary  to  give  examples  of  the  more 
common  ways  in  which  they  are  combined.  For  con- 
venience, I  have  separately  grouped  cases  depending 


Chap.  X.]      Hallucinations  of  Hearing.  251 

to  a  great  extent  upon  hallucinations.  As  the  sane 
mincl  is  built  up  of  sane  impressions,  so  there  are 
certain  insane  states  which  are  the  natural  outcome 
of  perverted  sense-impressions.  Whether  the  fault 
of  the  perversion  arises  from  brain  primarily,  or  from 
sense  primarily,  I  cannot  say  ;  but  the  groups  are 
natural. 

Unduly  sensitive  persons  are  best  understood  if 
we  compare  their  mental  state  with  that  of  a  man 
with  a  whitlow.  The  latter  never  seems  able  to  move 
or  act  in  any  way  without  injuring  his  finger.  It  seems 
to  him  as  if  everything  conspired  to  strike  him  on  the 
tender  spot.  In  healthy  unconsciousness  he  was 
ignorant  of  the  constant  unrecorded  impressions  this 
finger  received,  but  now  he  is  made  particularly  self- 
conscious.  Certain  insane  patients  are  like  the  man 
with  the  whitlow  \  every  action  which  takes  place  near 
them  causes  distress  and  pain,  and  all  things  distinctly 
and  painfully  affect  them. 

Simple  suspicion  with  hallucinations. — A  lady, 
about  whom  I  was  consulted,  was  in  the  habit  of 
taking  lodgings  for  herself  and  her  maid  at  various 
watering-places  in  England.  At  the  end  of  an  uncer- 
tain period,  she  would  quietly  give  notice  to  the  land- 
lady that  she  must  leave  at  once,  but  that  she  would 
pay  a  month's  rent  in  advance.  This  recurred  so 
frequently  that  her  friends,  whom  by  the  way  she 
shunned,  fancied  some  strange  delusion  must  be  the 
cause  of  her  frequent  flittings.  It  became  evident 
that  her  movements  were  due  to  "voices."  Each 
change  was  followed  for  a  time  by  comparative  free- 
dom from  mental  trouble  ;  but  later,  when,  in  fact, 
the  stimulus  of  moving  had  worn  off,  she  again  heard 
people  making  remarks  about  her.  Her  education 
and  bringing-up  had  so  fully  impressed  upon  her  her 
duties  as  a  lady,  that  when  annoyed  she  simply  took 
the  most  straightforward  way  of  leaving  the  annoyance 


252  Insanity  AND  Allied  Neuroses.    [Chap.  x. 

behind.  In  a  person  of  the  lower  orders  the  chances 
are  that  another  line  of  action  would  have  been 
followed,  and  some  one  or  other  would  have  been 
knocked  down. 

The  following  cases  are  characterised  by  what  I 
should  call  over-sensitiveness : 

Acute  hallucinationalinsanity,  curable. — A  young, 
over- wrought,  nervous  girl  (A.  W.),  who  has  spent 
far  too  much  time  in  book-learning  and  solitary  study, 
having  neglected  the  healthy  outdoor  exercises  of  her 
brothers  and  sisters,  and  having  shunned  meetings 
with  the  other  sex,  fails  in  appetite  and  digestion, 
and  suffers  considerably  from  constipation,  associated 
with  "  fulness  of  the  head."  Irregular  menstruation, 
sometimes  excessive  and  at  other  times  painful  or 
wanting,  still  further  alters  her  bodily  tone.  Prom 
being  amiable  she  becomes  irritable,  sleepless,  and 
weak  ;  she  gets  more  and  more  self-conscious ;  thinks 
she  has  not  done  the  best  thing  with  her  life,  or 
that  she  has  made  some  great  mistake ;  becomes  in- 
tolerant of  correction  by  relations  or  governesses, 
and  bursts  into  rages  for  which  she  does  not  appear 
contrite  afterwards.  Next,  she  avoids  going  out  of 
doors,  at  first  giving  as  an  explanation  that  she  does 
not  care  to  go  out ;  later,  she  owns  that  people  make 
remarks  about  her,  point  at  her,  refer  to  her  in 
one  way  or  another.  Unless  energetic  measures  are 
taken  early  in  these  cases,  such  as  removal  from 
friends  and  surroundings,  and  forcing  into  a  more 
objective  mode  of  life,  they  will  become  either  incur- 
able cases  of  delusional  insanity  or  weak-minded. 

Another  similar  case  (A.  S.)  developed  the  same 
symptoms  under  like  conditions,  but  circumstances 
rendered  it  impossible  for  her  to  have  any  other 
treatment  than  that  of  an  asylum ;  the  consequence 
has  been  that  the  ideas  of  inspection,  interference, 
and  the  like  have  become  fixed,  or  at  all  events  now 


Chap.  X.]   Hallucinations  of  Persecution.       253 

recur  so  consta,ntly  tliat  I  fear  she  will  never  more 
be  able  to  live  at  large.  It  is  striking  to  notice  the 
way  in  which  delusions  of  this  kind  will  grow  and 
become  mature,  and  remain  in  their  fully-developed 
state  for  many  years.  Thus,  from  time  to  time, 
paragraphs  will  be  noticed  under  the  heading  of 
"  police  news,"  in  which  a  lady  appeals  to  the  magis- 
trate for  protection,  or  will  ask  his  advice  as  to 
what  she  ought  to  do  to  prevent  herself  from  being 
poisoned.  Many  years  ago,  a  lady  of  nervous  inheri- 
tance was  left  a  widow  in  poor  cirumstances,  and  had 
a  severe  struggle  to  make  both  ends  meet.  With  a 
solitary  struggling  life  slowly  developed  ideas  that 
people  were  treating  her  badly,  morbid  sensations  ex- 
hibited themselves,  these  she  interpreted  as  the  effect 
of  poison ;  she  appealed  to  the  magistrates  and  took 
various  articles  of  food  to  be  analysed;  the  negative 
result  of  the  analysis  only  confirmed  her  ideas  that 
a  conspiracy  was  formed  against  her ;  she  became 
actively  troublesome  and  annoying,  and  had  to  be  sent 
to  an  asylum.  Her  hallucinations  grew  more  and 
more  fixed ;  with  her,  as  with  so  many  similar 
cases,  the  acuteness  of  their  exhibitions  varied  con- 
siderably ;  and  it  was  noteworthy  that  any  special 
cause  of  physical  depression  was  associated  with  an 
exacerbation  of  the  hallucinations.  She  would  behave 
quietly  and  appear  fairly  contented  for  weeks  together, 
when  she  would,  as  the  result  of  a  cold  or  a  fit  of 
indigestion,  complain  bitterly  that  she  could  not  live 
in  the  way  she  was  at  present  living  ;  for  that  on 
the  night  before  she  was  certain  that  something  was 
put  on  her  pillow  which  produced  profound  uncon- 
sciousness, not  natural  sleep,  and  that  during  her 
unconsciousness  all  sorts  of  terrible  things  had  been 
done  to  her.  She  was  fully  possessed  by  the  idea  that 
her  all-powerful  enemies  were  able  to  bribe  or  cozen 
the   attendants,    doctors,    and   every   one,    from    the 


2  54         Insanity  AND  Allied  Neuroses.     [Chap.  x. 

highest  to  the  lowest,  to  injure  her.  In  confirmation 
of  this,  she  would  say  her  hair  was  rapidly  coming 
out,  and  that  this  was  due  to  one  of  the  attend- 
ants puttiug  something  in  the  pomatum  or  oil  which 
was  sent  up  from  the  dispensary  specially  for  her; 
and  so  suspicious  was  she,  that  unless  the  medicine 
was  made  up  for  her  specially  and  given  directly  to 
the  head  attendant,  she  would  decline  to  take  it.  This 
condition  has  lasted  for  years,  and  will  continue  as 
long  as  she  lives. 

The  condition  of  her  case  naturally  leads  me  to 
refer  to  those  suffering  from  what  has  been  called 
the  delirium  of  persecution.  It  is  easy  to  under- 
stand how  a  patient,  who  first  of  all  believes  himself  to 
be  watched,  soon  becomes  persuaded  that  this  watch- 
ing is  initiated  by  some  one  and  for  some  object. 
As  I  pointed  out  in  melancholia,  the  mysterious  ex- 
planation is  the  one  which  appeals  most  readily  to 
persons  of  unsound  mind ;  and  the  man  who  is 
persecuted  at  once  refers  his  troubles  to  the  Jesuits 
or  the  Freemasons.  More  recently,  secret  societies 
and  Fenians  have  taken  the  parts  of  the  Freemasons 
and  Jesuits.  There  are  some  insane  people  who  attri- 
bute their  troubles  to  their  neighbours  because  the 
"  voices  "  appear  to  come  from  the  wall.  Detectives 
also  play  their  part  in  the  suspicions  of  this  class  of 
lunatics,  but  the  typical  cases  of  persecution  seem 
pretty  sure  to  pitch  upon  one  of  these  secret  associa- 
tions as  a  source  of  explanation  of  their  sufferings. 

The  following  case  is  an  example  :  William 
T.  W.,  single,  26,  writer  in  government  employ, 
one  sister  an  epileptic  and  insane,  phthisis  on 
mother's  side;  supposed  cause  was  impairment  of  his 
sight.  The  symptoms  came  on  steadily  a  month 
before  his  admission  to  the  hospital.  He  had  hal- 
lucinations of  hearing  "voices,"  and  galvanic  batteries 
disturbed  him.      He  believed  two  persons  conspired 


Chap.  X.]         Delirium  of  Persecution.  255 

together  to  injure  and  annoy  him.  He  complained  of 
his  head  being  affected.  His  general  health  was  fair, 
he  slept  well  when  not  disturbed,  and  ate  well.  The 
accompanying  letter  best  explains  his  ideas  : 

"  Bethlem  Hospital, 

"  St.  George's  Ed.,  Southwark,  S.E., 
"Oct.  6th,  1879. 

"Revd.  Sir, — I  beg  to  lay  before  you  the  facts  of 
my  most  distressing  case,  and  I  know  that  you  will, 
with  your  usual  kindness,  render  me  every  assistance 
you  can. 

"  I  was  brought  here  on  March  5th,  and  have  been 
subjected  to  galvanism  ever  since ;  that  is,  an  herma- 
phrodite tries  to  drive  me  out  of  my  mind  by  attempt- 
ing to  take  my  semen.  It  is  a  well-known  fact  in. 
the  medical  profession  that  it  can  be  done.  The  name 
of  the  lady  is  Miss  B.,  daughter  of  Mr.  B.,  of  Guy's 
Hospital.  The  students  at  Guy's  Hospital  know  some 
of  the  facts  of  the  case,  and  I  may  mention  that  Dr. 
Savage,  the  head  doctor  of  this  hospital,  a  Guy's  man, 
is  my  greatest  enemy,  because,  if  he  would  let  me  have 
a  Turkish  bath  I  could  get  rid  of  the  electricity  in  my 
body.  I  was  galvanised  so  as  to  become  a  living 
magnet  when  I  was  at  home  ill.  I  was  dragged  home 
by  three  policemen,  and  then  lodged  in  the  workhouse 
before  I  came  here,  and  was  neither  taken  before  a 
magistrate  nor  certified  by  two  doctors.  My  sister 
Susan  knows  something  of  the  case,  but  is  afraid  to 
tell  my  mother,  whom  I  cannot  convince,  as  she  does 
not  understand  what  galvanism  will  do,  and  will  not 
consult  a  medical  man. 

"I  have  written  to  Sir  J.  B.,  my  cousin,  but  T 
suppose  the  letters  are  stopped.  My  mother,  I  may 
say,  admits  that  I  am  not  insane,  but  I  think  my 
sister  Susan  works  upon  her  mind  with  some  tale  that 
it  will  be  eventually  for  my  benefit.     I  may  mention 


256         Insanity  AND  Allied  Neuroses.    [Chap.  x- 

that  there  are  two  gentlemen  in  this  hospital  who 
have  been  driven  out  of  their  minds  before  they  came 
here  by  galvanism.  I  am  sorry  to  trouble  you  in  the 
matter,  but  as  you  will  see  it  is  a  matter  of  life  and 
death  to  me,  I  hope  you  will  pardon  the  liberty  I  take. 
If  you  let  me  have  a  solicitor  to  see  me,  I  think  he 
could  obtain  my  release;  or  if  you  would  write  to  my 
mother  and  convince  her  that  galvanism  can  do  what 
I  say,  I  should  be  extremely  grateful.  I  may  say 
every  day  is  of  the  greatest  importance,  as  the  galva- 
nism annoys  me  more  when  I  attempt  by  clandestine 
means  to  obtain  my  release  from  this  horrible  place. 

''  I  am,  revd.  sir, 

"  Your  most  obedient  servant, 
"  To  the  Rev.  J—."  "  Thos.  W.  W. 

"P.S. — The  doctor  is  a  friend  of  Mr.  B.'s,  and 
has  admitted  before  the  students  that  I  am  being 
annoyed  by  galvanism." 

There  is  a  general  feeling  that  cases  of  insanity 
with  ideas  of  persecution  are  highly  unfavourable  ;  but 
I  would  rather  put  it  in  this  way  :  that  when  a 
patient  has  gradually  passed  through  the  various 
stages  referred  to,  when  he  has  suffered  from  simple 
unexplained  misery,  then  has  been  annoyed  by 
hallucinations  of  one  kind  and  another,  and  slowly 
developed  an  explanation  for  the  whole  of  these 
morbid  feelings,  that  the  disordered  process  has  been 
going  on  so  long  that  the  prospect  of  cure  is  small. 

Another  variety  of  delusional  insanity  is  seen  in 
what  might  be  called  the  inquisitive  or  meddlesome 
cases.  I  have  met  with  one  patient,  not  in  an  asylum, 
who  was  constantly  getting  into  trouble  as  a  result  of 
his  inquisitiveness.  He  had  a  feeling  that  everything 
had  some  connection  with  him,  and  would  ask  to  see 
private  letters,  or  would  thrust  his  nose  into  conver- 
sations in  no  way  intended  for  him,  the  consequence 


Chap.  X.]       Delirium  of  Persecution.  257 

being  that  he,  on  more  than  one  occasion,  got  severely 
chastised.  This  feeling  of  extension  of  personal 
interest  is  a  phase  of  mental  over-sensitiveness, 
another  side  of  which  is  seen  in  the  following  case  : 

Walter  A.,  single,  27,  no  neurotic  inheritance  ; 
supposed  cause  of  his  insanity  was  loss  of  fortune 
and  blighted  prospects  in  life.  He  received  a  severe 
injury  to  his  head  two  or  three  years  before  the 
appearance  of  his  nervous  symptoms.  He  attempted 
suicide  in  August,  1882,  at  the  time  believing  there 
was  a  system  of  persecution  against  him.  Every- 
thing depends  now  on  his  supposing  that  people  are 
either  whispering  the  word  hougre,  or  are  suggesting 
that  he  is  a  very  objectionable  man.  Every  act  or 
word  is  misconstrued,  yet  this  patient  retains  his 
ordinary  mental  capacity.  I  annex  an  account  of  the 
case  compiled  from  particulars  given  by  himself. 

"  When  I  set  foot  upon  French  soil,  two  years  ago, 
I  discovered  a  system  of  en  arriere  persecution  of 
people  constantly  taking  notice  of  me,  and  supposing 
me  to  have  the  appearance  of  excessive  venery.  This 
671  arriere  persecution  was  introduced  into  every 
action  of  my  life.  I  was  in  perfect  health.  When  in 
France  I  went  to  various  places,  and  spent  some  time 
at  Dijon,  where  I  was  introduced  into  good  society. 
I  was  kindly  treated  in  every  way,  but  I  still  thought 
that  this  en  a7'riere  persecution  followed  me  every- 
where I  went.  My  father  was  very  well  off,  and  I 
would  have  been  so  had  my  father  not  lost  almost 
everything  he  possessed,  having  had  his  mill  destroyed 
by  fire.  This  circumstance  did  not  affect  my  mind  in 
any  way.  I  had  a  disappointment  in  love,  but  told 
nobody  of  it.  This  also  did  not  affect  my  mental 
balance.  The  character  of  society,  at  the  present 
time,  is  corruption,  and  I  believe  that  to  be  the  cause 
of  my  illness,  my  mind  being  sensitive.  My  will  had 
been  so  affected  by  this  en  ar7'iere  persecution,  that  I 
K — 14 


258         Insanity  and  Allied  Neuroses.    [Chap.  x. 

got  into  a  despairing  condition,  and  threw  myself  over 
Westminster  Bridge,  when  I  was  rescued  by  some 
bargemen,  but  I  felt  no  regret  at  doing  this  rash  act. 
I  considered  that  there  was  no  possibility  for  me  to 
accomplish  any  work  in  this  world,  therefore  I 
attempted  suicide.  Even  now  I  do  not  see  my  way 
to  accomplish  any  work,  but  if  I  had  absolute 
seclusion  I  should  be  able  to  do  so ;  at  present, 
however,  I  see  no  chance  of  it.  I  hear  persons 
talking  and  discussing,  in  obscene  terms,  my  condition, 
which  offends  me,  and  this  occurs  more  when  I  am 
subjected  to  this  en  arriere  persecution.  I  think  the 
appearance  of  my  eyes  is  that  of  excessive  venery,  and 
other  people  think  so  likewise.  Since  I  have  been  in 
Bethlem  this  belief  is  not  more  fixed,  and  it  remains 
as  it  was.  I  think  that  disappointment  influenced 
my  thought  very  much  and  undermined  my  life,  and 
that  my  nervous  constitution  is  also  being  slowly 
undermined,  and  that  my  lungs  are  a  little  affected. 
My  ai)petite  is  good,  but  my  rest  is  bad,  having  had 
hallucinations. " 

Another  variety  of  delusional  insanity  is  com- 
mon among  women  j  thus,  among  younger  women 
we  occasionally  meet  with  those  who  imagine  that 
they  have  been  injuriously  affected  by  some  man ; 
and  such  cases  will  write  compromising  letters,  or 
make  accusations  against  gentlemen,  demanding  satis- 
faction, or  that  their  characters  shall  be  cleared 
before  the  public.  I  would  say.  as  a  practical  point, 
that  such  cases  are  not,  in  my  experience,  those 
who  demand  money.  It  is  not  a  purely  mercenary 
consideration  which  they  require  ;  the  ways  in  which 
they  believe  themselves  to  be  affected  are  almost 
endless.  Thus,  one  girl  said  that  a  man  at  a  distance 
caused  her  to  feel  all  sorts  of  strong  sexual  desires,  and 
that  she  was  sure  by  some  means  or  other  he  intended 
to  get  the  better  of  her. 


Chap.  X.]  .  Sexual  Delusion.  259 

The  ignorance  of  all  physiology  in  which  English 
girls  are  brought  up,  associated  with  narrow  religious 
teaching,  is  answerable  for  a  certain  number  of  cases 
of  this  descriiDtion,  A  young  girl  at  puberty  feels 
strange  and  hitherto  inexperienced  sensations  and 
desires  j  she  becomes  alarmed  and  anxious,  and  in 
some  this  gives  place  to  a  nervous  exaggeration  of  the 
feeling  of  depression  which  is  so  common  after  or  with 
menstruation.  The  morbid  sensibility  further  dwelt 
upon  and  explained,  starts  a  delusion,  which  if  not  got 
rid  of  develops  into  a  chronic  incurable  condition  of 
the  kind  I  am  now  considering.  Other  cases  in  which 
this  type  of  delusion  is  common  are  those  of  single 
women  about  forty-five  years  old. 

The  following  (McM.)  is  a  good  example  :  This 
patient  was  forty-three,  single,  with  insanity  on  the 
father's  side.  She  had  been  a  governess,  and  had 
suffered  from  one  previous  attack  of  insanity.  The 
first  symptom  noticed  was  her  refusal  to  take  food. 
She  believed  people  were  wishing  to  injure  her ;  she 
feared  she  would  be  lynched  by  the  mob,  and  insisted 
upon  going  straight  to  the  Queen.  She  heard  dis- 
turbances in  the  street  which  really  did  not  exist. 
During  the  night  she  was  convinced  there  were  men 
in  the  hotel  who  were  influencing  her  muscular  and 
nervous  systems,  which  she  believed  they  were  able 
to  do  without  in  any  way  approaching  her.  She 
screamed  violently  at  night,  and  endeavoured  to  escape 
by  means  of  the  window.  She  said  that  disagree- 
able vapours  were  forced  into  her  room,  this  symptom 
being  not  uncommon  in  similar  cases.  She  imagined 
that  all  the  men  with  whom  she  was  brought  into 
direct  contact  were  wicked  and  unworthy,  and  that 
they  fell  under  the  influence  of  a  certain  major  who 
was  plotting  to  ruin  her.  This  lady  was  constantly 
leaving  good  situations  without  cause  given,  for  the 
reason    that    she    fancied    this    major    was    following 


2  6o         Insanity  AND  Allied  Neuroses,    [Chap.  x. 

her,  or  was  in  the  house  trying  to  get  at  her.  With 
her,  as  with  many  others  suffering  in  a  like  manner, 
there  were  ideas  that  the  wicked  major  had  a  power 
of  transforming  himself  and  appearing  in  different 
ways  and  in  various  forms.  Such  a  case  as  this  is 
absolutely  incurable. 

Another  marked  case  is  that  of  a  woman  (L.)  who 
was  admitted  into  Bethlem  in  May,  1882,  under  the 
delusion  that  she  was  followed  by  two  men  and  a 
woman  who  were  constantly  prying  into  her  affairs, 
and  she  said  she  would  be  glad  if  I  could  secure  the 
services  of  a  detective  to  arrest  them.  I  asked  her 
how  she  felt  here.  She  answered,  "  They  are  con- 
stantly annoying  me  vdth  telephones ;  and  those  wh  o 
annoy  me  are  a  man  and  woman  who  constantly  watch 
me  ;  they  look  into  my  windows  ;  they  read  everything 
I  write ;.  they  know  my  thoughts  before  I  speak ; 
they  prick  me  with  a  needle  fixed  in  a  wire,  and  they 
even  get  under  my  bed.  They  have  constantly  car- 
ried on  this  system  of  troubling  me  since  I  was  at 
Marazion  many  weeks  ago,  and  I  believe  that  every 
workman  in  the  neighbourhood  is  a  conspirator  with 
the  telephone  people  to  annoy  me."  In  this  case, 
again,  I  fear  there  is  no  prospect  of  cure.  The  only 
savinoj  element  is  that  it  is  associated  with  the 
climacteric,  and  certain  cases  recover  then  which  other- 
wise would  have  to  be  considered  incurable.  From  a 
practical  point  of  view,  it  is  noteworthy  that  patients 
may  be  extremely  dangerous,  by  making  accusations 
on  the  one  hand,  or  by  attempting  to  protect  them- 
selves on  the  other. 

Delusional  insanity  with  a  strongly  sexual  char- 
acter is  common  also  in  widows.  We  have,  then,  this 
very  distinct  group  of  cases  in  which  there  are  per- 
versions of  feeling  connected  with  the  reproductive 
organ,  associated  with  other  perversions  of  the  special 
senses,  such  as  hallucinations  of  hearing  and  of  smell. 


Chap.  X.]  Delusions.  261 

These  cases  are  most  common  in  single  women  of 
mature  age  and  in  widows. 

They  are  dangerous  from  their  false  accusations, 
and  they  are  rarely  curable. 

Another  case,  somewhat  different,  is  that  of  a 
music  teacher  (M.  E.  B.),  single_,  aged  31.  Her 
father  committed  suicide,  and  her  maternal  aunt  is 
now  in  an  asylum.  During  the  past  two  years  she 
had  exhibited  symptoms  of  mental  unsoundness, 
marked  by  nervous  instability  and  fancifulness.  Men- 
struation had  been  regular,  and  her  general  health 
good.  She  attempted  to  strangle  herself  because  of 
her  feelings  of  being  pursued.  She  heard  voices  ac- 
cusing her,  but  the  idea  that  most  especially  an- 
noyed her  was  that  everything  she  came  in  contact 
with  was  stuffed  with  matches  and  pins.  Her  look  of 
worried  anxiety,  when  she  moved  from  one  place  to 
another,  was  very  striking,  so  that  on  meeting  her  you 
at  first  imagined  that  she  had  lost  something  and  was 
seeking  for  it.  She  would  at  once  tell  you  that  the 
annoyance  from  these  pins  was  extreme.  When  she 
got  up  in  the  mornings,  and,  having  washed  herself,  put 
on  her  first  garment,  she  at  once  became  uneasy,  and 
reversed  it  again  to  see  that  there  were  really  no  pins 
there.  This  process  of  dressing  and  undressing  occu- 
pied so  much  time,  as  a  rule,  that  she  was  three  hours 
every  morning  before  she  could  go  to  breakfast.  She 
would  talk  about  her  case  in  a  fairly  matter-of-fact 
way ;  and  would  ask  whether  it  were  better  rapidly  to 
get  into  her  clothes,  to  submit  to  or  struggle  against 
the  ideal  misery,  or  whether  it  were  better  for  her  to 
examine  and  re-examine  till  she  had,  at  all  events, 
partly  or  temporarily  satisfied  herself.  Such  cases 
occur,  as  I  have  said,  chiefly  in  women.  They  are  as- 
sociated with  fear,  dread,  doubt,  and  suspicion.  They 
occur,  I  believe,  chiefly  in  those  with  insane  inheri- 
tance; in  fact,  in  my  experience  these  cases  are  but 


262  Insanity  AND  Allied  Neuroses.    [Chap.x. 

slow,  natural  developments  of  a  temperament  which 
may  be  called  the  insane  one  ;  and  just  as  there 
are  certain  patients  with  moral  deficiencies  who  have 
strong  insane  inheritance,  so  there  are  others  who 
come  of  insane  stock  and  are  predisposed  to  develop 
delusional  insanity.  The  causation  of  this  form  of  in- 
sanity is  very  obscure.  There  are  undoubtedly  pre- 
disposing influences,  as  in  the  case  of  an  occupation 
which  tends  to  a  subjective  life,  so  that  the  middle- 
aged  governess  and  the  struggling  widow  seem  specially 
liable  to  be  aflected. 

I  must  next  refer  to  a  group  of  delusional  cases 
with  exalted  ideas.  The  "Queens"  of  an  asylum  are 
many,  and  as  a  rule  must  be  looked  upon  as  incurable. 
The  cases  I  have  hitherto  been  considering  have  been 
found  to  sufier  from  hallucinations  of  their  senses ; 
but,  in  this  last  group,  frequently  no  hallucinations 
exist,  but  there  are  delusions  of  a  pronounced  type. 

Examiile  of  delusional  insanity  with  exaltation. — 
A  lady,  who  had  been  brought  up  in  luxury  and  sur- 
rounded by  wealth,  was  suddenly  thrown  into  a  state 
of  want  through  the  insolvency  of  her  father.  She 
became  more  and  more  exacting,  and  more  impressed 
with  the  position  to  which  she  believed  herself  still 
entitled.  Slowly  she  became  more  reserved,  and  in 
the  end  was  impressed  with  the  idea  that  she  was  a 
queen,  and  that  everything  in  the  asylum  belonged  to 
her.  From  the  time  that  this  idea  became  fully  esta- 
blished she  has  in  no  way  changed,  but  behaves  as  a 
lady,  occupying  herself  in  art  of  a  rather  wild  descrip- 
tion, and  with  literature  in  the  shape  of  a  French  dic- 
tionary, which  she  is  committing  to  memory,  and  she 
takes  a  fixed  and  supreme  position  as  Queen  Anne. 
In  this  happy  belief  she  will  remain  as  long  as  she 
lives.  The  development  of  ideas  of  grandeur  among 
women  of  this  class  is  interesting  ;  it  is  a  slow,  steady 
growth,   and  contrasts  with  the  exaltation  which  is 


Chap.  X.]  Delusional  Jealousy.  263 

met  with  in  youths  without  experience  of  the  world, 
which  is  the  simple  unrestrained  expression  of  buoy- 
ancy ;  and  on  the  other  hand  it  contrasts  with  the 
exaltation  of  the  general  paralytic,  where  I  believe  loss 
of  self-control  and  increased  vital  action  explain  the 
temporary  exaltation,  which  is  like  the  flare  of  the 
rapidly-consuming  wick.  The  mode  of  the  growth  of 
the  exaltation  of  such  cases  is,  to  my  mind,  a,s  follows  : 

Patients,  hoping  for  a  success  which  they  are 
never  likely  to  attain,  build  castles  in  the  air  which 
often  become  realities  to  them.  It  does  not  follow 
that  all  the  castles  should  be  of  the  same  type.  One 
girl  dwelt  upon  the  image  of  her  doctor  till  she  be- 
lieved he  was  to  be  her  husband.  It  mattered  not  that 
he  was  already  a  married  man  with  a  family.  She  was 
convinced  that  obstacles  of  that  kind  could  be  easily 
overcome,  and  that  the  person  who  represented  himself 
to  be  a  married  man  really  was  not  married  at  all. 
In  her  case  no  amount  of  change  of  scene  or  occupa- 
tion made  any  appreciable  difference  in  her  condition. 

Another  dangerous  and  troublesome  variety  of 
delusional  insanity  is  associated  with  jealousy.  A 
married  person  will  sometimes  get  a  fixed  idea  that 
the  husband,  or  wife,  as  the  case  may  be,  is  incon- 
stant, and  the  very  slightest  occurrences  may  be  a 
convincing  proof  of  the  truth  of  such  accusations. 
A  good  example  of  the  danger  and  of  the  ditii- 
culty  of  such  cases  is  that  of  a  man,  married,  aged 
forty,  who  had  a  large  family.  He  was  of  a  ner- 
vous, emotional  disposition,  given  greatly  to  self- 
exaltation,  and  spent  most  of  his  time  in  what  he 
thought  was  doing  good  to  others,  but  allowing  his 
wife  to  be  the  bread-winner.  She  led  an  active,  busi- 
ness-like life,  and  was  successful  in  her  endeavours.  The 
husband  began  to  wonder  how  she  got  on  so  well,  and 
put  it  down  as  due  to  immorality ;  although  one  would 
have  supposed  that  his  experience  of  life  would  have 


264         Insanity  AND  Allied  Neuroses.     [Chap.  x. 

taught  him  that  a  middle-aged  married  woman,  with  a 
family  and  small  pretensions  to  good  looks,  would  not 
have  much  opportunity  of  making  a  fortune  immorally. 
Still,  haunted  by  the  idea  that  she  was  receiving  visits 
from  men,  he  tried  every  conceivable  trick  to  surprise 
and  detect  her,  and  exposed  her  to  all  sorts  of  physical 
and  moral  indignities  to  trace  her  evil  ways.  He  be- 
came dangerous,  threatening  her  and  vowing  vengeance 
upon  those  whom  he  considered  as  her  paramours. 
He  was  sent  to  Bethlem,  where  he  behaved  him- 
self perfectly  well  as  far  as  appearances  went, 
and  it  was  with  considerable  difficulty  that  I  was 
able  to  detect  his  delusions,  till  one  day  my  name 
was  linked  with  that  of  his  wife  as  co-respondent. 
This  condition  of  delusion  remained  unaltered  for 
some  months ;  but  I  found  him  one  day  working 
and  making  himself  useful  in  the  wards,  and  shortly 
after  he  made  a  statement  that  he  had  lost  all  his 
suspicions,  and  owned  himself  to  have  been  deluded. 
A  change  to  the  country  was  followed  by  a  period  of 
apparent  health  ;  but  after  a  few  months  at  home  the 
whole  of  his  suspicions  returned,  and  he  had  to  be 
secluded  for  the  safety  of  his  wife  and  friends.  Since 
then  he  has  been  for  some  years  at  a  county  asylum, 
where,  I  believe,  he  will  have  to  spend  the  rest  of  his 
life,  as  any  return  to  his  friends  will  be  associated 
with  a  recurrence  of  his  delusions,  which  will  prove  a 
source  of  annoyance  and  danger  beyond  the  limits  of 
endurance. 

I  have  frequently  been  struck  by  the  connected 
and  reasonable  way  in  which  a  patient  would  talk 
about  his  delusion.  In  fact,  unless  one  was  absolutely 
in  a  position  to  contradict  his  premisses,  he  must 
admit  the  conclusion.  Delusions  of  jealousy  may  how- 
ever be  lost,  and  recovery  be  complete  and  permanent. 
One  man  told  me,  in  the  most  circumstantial  way,  the 
whole  history  of  his  detection  of  his  wife's  wickedness, 


Chap.  X.]  Delusional  Jealousy.  265 

describing  graphically  the  man,  the  place,  and  the  occa- 
sion; winding  up  with  an  admission  that  when  received 
into  Bethlem  he  was  suffering  from  mental  depression, 
the  result  of  this  sad  discovery ;  and  thanking  me 
for  my  kindness,  he  said  he  was  anxious  to  leave  the 
hospital,  but  not  to  return  to  his  wife,  who  must  now 
be  separated  from  him  for  ever.  I  was  astonished, 
but  allowed  him  to  leave  the  hospital  for  a  month  to 
live  with  a  married  son.  At  the  end  of  the  month  he 
returned,  and  with  tears  told  me  that  the  accusation 
he  had  made  against  his  wife  was  utterly  unfounded, 
and  that  a  more  considerate,  conscientious,  and 
honourable  woman  never  lived ;  that  the  only  explana- 
tion he  could  give  was,  that  it  was  the  mental  perver- 
sion which  disease  is  said  to  cause,  for  his  married  life 
had  been  an  unbroken  calm. 

In  the  next  case  a  most  extraordinary  series 
of  delusions,  associated  with  hallucinations,  had 
slowly  developed.  The  patient's  (M.  R.)  own  version 
was,  that  on  a  certain  evening,  he  and  his  wife  being- 
engaged  playing  a  game  at  cards,  the  latter  left  the 
room,  and  from  that  time  there  was  a  complete  con- 
fusion ;  in  fact,  although  he  remained  just  as  he  had 
been  before  this  wife  of  his  was  spirited  away,  another 
woman,  resembling  her  in  every  outward  particular, 
took  her  place,  assuming  her  seat  at  the  card  table, 
and  accompanying  him  to  bed.  He  admitted  that 
she  was  the  mother  of  some  of  his  children ;  he  be- 
lieved that  a  strange  but  hideous  play  was  being 
enacted,  and  that  the  very  names  of  his  children  were 
made  to  react  upon  them  in  what  he  called  a  "name- 
play  ; "  that  their  whole  lives  were  to  be  sacrificed  for 
the  supposed  amusement  of  Jesuits  or  some  other 
secret  society.  The  following  report  siifficiently  indi- 
cates the  condition  in  which  he  was  admitted  into 
Bethlem  :  He  was  received  on  the  10th  of  February, 
1883;    has    delusions  that    certain  people   whom   he 


266  Insanity  AND  Allied  Neuroses.    [Chap.  x. 

believes  to  be  Roman  Catholics  are  practising  ghastly 
cruelties  on  him,  by  watching  his  wife  and  children, 
and  substituting  duplicates  for  them ;  thinks  he  is  a 
duplicate,  and  says  they  are  always  signalling  at  him. 
He  speaks  of  the  cruelties  as  something  dreadful,  and 
says  there  is  a  ghastly  Roman  Catholic  plot  over  the 
whole  country,  which  causes  substitutes  to  be  made 
for  all  his  relatives  ;  that  the  originals  are  carried  olf 
to  asylums  and  elsewhere,  where  they  are  cruelly 
treated ;  that  words  have  special  meanings  apart  from 
their  ordinary  signification,  and  that  these  meanings 
are  only  known  to  a  few  of  the  initiated  ;  complains  of 
loss  of  power  in  the  extensor  muscles  of  the  right  leg 
(no  pain  or  tenderness)  ;  the  right  foot  drags  slightly. 
The  prospect  of  any  alteration  in  this  case  is  of  the 
smallest  kind  :  first,  from  the  length  of  time  during 
which  the  symptoms  have  been  developing,  and 
secondly,  from  the  completely  organised  form  which 
they  have  assumed. 

Another  variety  of  delusional  insanity  is  what  has 
been  called  "  symbolising  insanity."  Patients,  generally 
of  the  educated  class,  of  middle  age  or  advancing  years, 
have  a  sensitiveness  to  their  surroundings,  very  like 
that  I  have  already  described,  but  with  them  the 
limits  or  suggestions  refer  indirectly,  and  not  always 
unpleasantly,  to  them. 

One,  a  most  trustworthy  business  man,  developed 
the  idea  that  honours  were  in  store  for  him  if  he  only 
knew  the  way  to  get  them ;  he  believed  there  was  a 
secret  code  which  he  had  to  find  out  and  act  upon. 
He  would  take  his  dinner,  and  then  deeply  lament 
that  he  had  done  it,  fearing  he  might  have  neglected 
his  opportunity.  At  night  he  would  watch  and  pray, 
like  a  knight  of  old  before  his  armour,  fearing  his 
chance  might  come  unawares.  Any  movement  of  the 
slightest  kind  affected  him,  and  he  would  not  rest  till 
he  had  assured  himself  that  nothing  had  been  meant. 


Chap.  X.]  Symbolising  Insanity.  267 

Year  after  year  has  passed,  and  still  he  is  longing 
for  honours  which  never  come,  and  seeing  fresh 
symbols  in  the  simplest  of  actions. 

The  subjoined  is  a  very  good  example  of  the 
class.  In  this  case,  conscientious,  hard,  intellectual 
work  which  was  not  properly  appreciated,  created 
discontent  and  a  feeling  of  injustice  which  caused 
him  to  seclude  himself,  and  brood  over  his  misfor- 
tunes, till  he  became  possessed  by  the  idea  that  there 
was  a  symbolism  in  everything  which  he  saw  or  ex- 
perienced ;  and  the  end  is  that  this  brilliant  mind  is 
now  entirely  self-contained,  its  circle  of  interest  nar- 
rowing from  day  to  day. 

Symbolising. — H.  L.,  single,  aged  45,  school- 
master, no  insane  inheritance ;  the  cause  is  supposed 
to  have  been  sunstroke,  but  there  was  a  question 
of  acute  alcoholism  preceding  it.  Money  losses,  and 
failure  of  his  school  in  consequence  of  fever  breaking 
out  among  the  pupils,  were  the  chief  factors  in  finally 
developing  symptoms  of  insanity.  These  seemed  causes 
enough  in  themselves,  but  he  also  formed  a  very  good 
example  of  the  natural  development  of  insane  symp- 
toms from  eccentric  habits  and  solitude.  He  became 
melancholy,  restless,  and  possessed  by  ideas  that 
everything  had  some  reference  to  him,  and  so  im- 
pressed was  he  by  this  that  he  threatened  to  commit 
suicide  to  get  rid  of  it.  He  had  in  earlier  life  been 
brought  up  with  a  young  lady  as  foster-brother,  and 
when  she  married  it  seemed  to  have  caused  him  a  good 
deal  of  worry  ;  not  that  he  had  made  any  advances 
towards  her,  but  when  it  happened  that  she  was  re- 
moved from  him  he  seemed  deeply  aJflfected.  This, 
however,  passed  ofi",  and  only  reappeared  when 
symptoms  of  insanity  were  developed.  Then  he  be- 
came possessed  by  the  idea  that  this  lady  was  really 
his  spiritual  wife,  and  not  only  did  he  claim  her, 
but  he  claimed  her  children  too.     His  diary,  which 


268  Insanity  AND  Allied  Neuroses.    [Chap.  x. 

lie  kept  partly  in  shorthand  and  partly  in  ordinary 
writing,  gives  a  very  good  idea  of  the  morbidly  sensi- 
tive condition  in  which  he  was  ;  for  one  day  he  would 
imagine  the  flower-pots  of  his  opposite  neighbours 
were  placed  in  twos,  thereby  meaning  he  ought  to  be 
paired.  On  another  morning  he  would  fancy  the 
flower-pots  were  arranged  in  threes  or  singly,  and 
this  again  had  an  allusion  to  his  anomalous  condition, 
being  spiritually  married  and  yet  single.  He  refused 
food,  but  declined  to  enter  into  any  argument  as  to 
whether  he  were  justified  or  not  in  trying  to  starve 
himself.  During  the  whole  time  that  he  has  been 
under  observation  he  has  refrained  from  having  any 
communication  with  or  associating  in  the  amusements 
or  occupations  of  other  patients.  He  looks  earnestly 
on  the  floor,  and  is  doubtless  occupied  with  hallucina- 
tions, this  hypothesis  being  borne  out  by  his  diary,  in 
which  he  constantly  refers  by  name  to  his  spiritual 
friend.  I  append  a  few  of  his  notes  taken  from  his 
diary : 

"  Ghosty,  dear,  why  are  you  like  a  comet  %  Be- 
cause you  are  so  impalpable  %  No.  Because  you 
make  us  all  think  of  our  latter  end?  Good,  but  not 
it;  try  again.  Because  it  will  be  100,000  years 
before  we  see  you  again  %  Better ;  this  would  be  the 
height  of  conjugal  felicity  ;  what  you  aim  at,  Ghosty, 
is  it  not  %  No.  This  is  it,  Ghosty,  dear  :  because, 
as  the  comet  approaches  the  centre  of  light,  the  size 
of  the  tail  represents  the  waste  of  the  head.  Conser- 
vation of  force,  Ghosty!  You  can't  get  over  that; 
that  is  too  big  for  you  even.  Good  night,  Ghosty." 
On  another  page  he  writes  to  the  Ghost  as  follows  : 
"  Mon  cher  ombre,  je  viens  de  voir  '  La  Dame  aux 
Camelias ; '  I'entree  du  pere  k  la  fin  du  troisieme 
acte  est  bien  arrangee,  n'est-ce  pas  %  J'ai  pense  ^  toi, 
et,  en  criant,  'Mon  ombrelle,  mon  ombrelle  !'  je  me 
suis  jete  dans  tes  bras,  en  imagination,  mon  cheri,  tu 


Chap.  XL]  Moral  Insanity.  269 

sais.      Vis  a  vis  il  y  avait  le  Comte  D y   et  sa 

bonne.     J'ai  remarque  a  moi-memej  '  Yoila  un 

mariage  comme  il  faut.'     Ah  !  mon  ombre,  mon  ange 
gardien,  tu  sais  tout ;  et  tout  ce  que  tu  fais  est  pour 

le  mieux.  *'  Ton  devoue, 

(« » 

In  all  the  cases  which  I  have  already  described 
under  the  head  of  delusional  insanity,  it  will  have 
been  noticed  that  some  perversion  of  sense,  halluci- 
nations of  one  kind  or  another,  have  slowly  led  up  to 
the  development  of  fixed  delusions,  and  I  fear  that 
no  amount  of  medical  or  general  treatment  is  in  any 
way  likely  to  cure  such  cases.  They  are  necessarily 
dangerous  both  to  themselves  and  others  during  a 
considerable  part  of  their  course  ;  but,  in  certain  of 
the  cases,  with  time  comes  on  pronounced  weak- 
mindedness,  or  the  delusions  seem  to  become  confined 
within  definite  limits,  and  in  that  manner  are  more 
easily  reckoned  upon  ;  and,  consequently,  in  some  of 
these  latter  cases  patients  may  be  treated  away  from 
an  asylum. 


CHAPTER    XI. 

MORAL     INSANITY. 

Loss  or  perversion  of  the  liiglier  social  acquirements  as  :  a  symptom 
of  disease — a  result  of  disease — a  result  of  inheritance — 
Represented  by  lying  and  thieving — Representing  loss  of  con- 
trol over  the  appetites — Precocity — Special  ability  for  music, 
mathematics,  or  remembrance  of  details. 

All  modern  writers  admit  that  there  may  be  mental 
disorder  in  which  the  intellect  is  either  fairly  deve- 
loped or  unaffected  by  disease,  and  yet  in  which  great 
moral  disorder  or  defect  is  present.  It  has  been 
maintained  that  where  moral  perversion  exists,  there 


270         Insanity  AND  Allied  Neuroses.    [Chap.  xi. 

will  also  be  found  some  intellectual  want ;  and  a 
similar  remark  has  become  a  truism  as  to  the  sane 
mind  in  the  sane  body.  It  is  not  convenient  or  pos- 
sible to  classify  all  forms  of  mental  disorder  according 
to  bodily  symptoms,  nor  is  it  possible  to  deny  that 
moral  disorders  may  exist  with  little  or  no  intellectual 
change.  Although  moral  perversion  in  such  cases  is 
generally  associated  with  intellectual  weakness  of  one 
kind  or  another,  yet  there  are  cases  in  which  the 
chief  mark  of  disorder  is  seen  in  breaches  of  the 
moral  laws  which  society  has  found  it  necessary  to 
establish.  There  is  a  borderland  in  which  persons 
must  be  placed  who  are  partly  bad  and  partly  mad  ; 
there  are  people  who  have  not  the  power  of  control- 
ling their  lower  instincts  ;  in  whom  the  animal  pro- 
pensities may  override  the  intellectual.  It  is  very 
easy  to  pass  from  the  consideration  of  these  borderland 
cases  to  those  of  the  criminal  classes  pure  and  simple  ; 
the  criminal  classes  must  be  looked  upon  from  the 
nervous  stand-point  as  unstable  and  prone  to  develop 
symptoms  of  nervous  disease  more  readily  than  the 
non-criminal  classes.  But  besides  the  class  of  persons 
who  may  be  said  never  to  have  developed  into  a 
higher  moral  and  intellectual  state,  there  are  some 
who,  having  been  once  sane  and  self-restrained,  be- 
come vicious  as  a  result  of  nervous  disorder ;  and 
there  is  also  a  special  class  of  young  patients  who 
from  the  first  exhibit  no  distinctive  intellectual  loss, 
but  miay,  in  fact,  be  brilliant  in  some  particulars,  and 
yet  without  any  moral  sense. 

Pirst,  then,  after  attacks  of  insanity  patients  may 
become  vicious.  I  have  known  a  man  come  into  an 
asylum  with  a  history  of  good  conduct  and  strictly 
moral  behaviour.  He  has  had  a  short,  sharp  attack 
of  mania,  followed  by  a  slight  period  of  depression ; 
but  from  that  time,  although  sent  from  the  asylum. as 
having  recovered,  he  has  been  an  entirely  changed  man, 


Chap,  XL]  Kleptomania.  '  271 

and,  instead  of  being  sober  and  moral,  lias  now  become 
intemperate  and  vicious.  -  It  is  true  that  one  some- 
times sees  the  reverse  take  place,  so  that  I  have  known 
a  husband  come,  years  after  his  wife  has  been  dis- 
charged recovered  from  an  attack  of  insanity,  and  say 
that  not  only  has  his  wife  remained  well  since  her 
attack,  but  has  been  a  changed  woman,  being  more 
amiable  and  self-sacrificing  than  she  was  before.  This 
is  no  single  instance,  but  represents  the  change  I  am 
here  referring  to,  a  moral  change,  a  change  in  temper 
and  disposition  succeeding  an  attack  of  insanity. 

Not  only  does  one  see  a  moral  perversion,  as  gene- 
rally understood,  but  I  have  seen  at  least  a  dozen  cases 
in  which  the  patients  have  become  what  is  called  klep- 
tomaniacs after  an  attack  of  insanity^  and  they  will 
act  with  the  utmost  deliberation  and  with  apparent 
power  of  calculation  and  combination  to  effect  their 
purposes.  Thus,  a  French  governess  (Marie  S.),  age 
26,  single,  with  no  inheritance  of  insanity,  was  ad- 
mitted into  Bechlem  in  March,  1871.  She  was  suffer- 
ing from  active  melancholia  (said  to  be  caused  by 
sunstroke),  associated  with  constant  restlessness,  pick- 
ing her  dress  and  fingers.  Complaints  were  made  that 
she  was  fiilthy  in  her  habits.  She  wanted  some  one  to 
kill  her,  or  to  be  allowed,  as  she  said,  to  sleep  for  a 
fortnight.  I  may  say  there  was  some  ground  for  be- 
lieving that  the  French  war  of  1870  had  caused  her  a 
good  deal  of  anxiety.  She  improved  considerably  in 
general  health,  but  persisted  in  saying  she  was  a 
devil  ;  but,  notwithstanding  this,  she  continued  to  be 
active,  pleasant,  and  rational  in  conversation.  Later 
it  was  found  that  she  had  been  in  the  habit  of  purloin- 
ing articles  of  clothing  belonging  to  other  patients, 
securing  in  the  most  adroit  way  the  best  articles,  espe- 
cially those  which  were  less  recognisable,  and  effacing 
the  various  marks  in  ways  which  one  could  never  dis- 
cover.    She  was  as  able  a  liar  as  she  was  a  thief,  and 


272  Insanity  and  Allied  Neuroses.  [Chap.  xi. 

protests  of  amendment  and  contrition  were  always 
followed  in  a  short  time  by  fresh  depredations. 
This  conduct,  we  found,  was  in  direct  opposition  to 
all  her  old  habits.  She  herself  owned  to  the  inability 
she  felt  to  control  this  desire  for  appropriating 
goods,  and  said  that,  after  all,  she  must  be  a  devil  to 
do  such  things. 

At  the  present  time  v.^e  have  in  Bethlem  another 
case  in  which  a  woman  who  has  suffered  from  insanity 
following  child-birth  has  become  stout  and  weak- 
minded  ;  and  who,  although  a  useful  drudge,  is  un- 
trustworthy where  portable  property  is  concerned.  I 
sometimes  make  a  distinction  between  those  of  our 
patients  who,  being  weak-minded,  are  like  magpies  and 
collect  anything  that  is  bright  and  movable,  and  the 
other  class,  such  as  those  above  described,  who  are 
adept  and  cunning  thieves,  and  will  own  and  recognise 
their  faults,  though  they  are  unable  to  amend  them. 
Whilst  speaking  of  kleptomania  and  moral  insanity,  I 
would  remark  that,  almost  yearly,  cases  are  admitted 
into  Bethlem  who  have  been  taken  before  the  magis- 
trates accused  of  theft,  many  such  cases  proving  to  be 
in  the  early  stage  of  general  paralysis  of  the  insane. 
In  my  experience  it  has  been  more  common  to  find 
the  moral  perversion  represented  by  kleptomania  fol- 
lovmig  an  attack  of  insanity,  among  women  than  among 
men.  But  when  it  occurs  as  the  result  of  direct  in- 
sane inheritance,  it  may  take  place  in  either  sex  at  any 
age.  It  is  unnecessary  to  describe  in  detail  the  other 
moral  perversions  which  may  follow  acute  insanity  ; 
suihce  it  to  say  that  intemperance  in  eating  and 
drinking,  in  lust,  in  desire  for  property  or  for  any  low 
taste,  may  occur  in  such  cases. 

The  next  group  of  cases  of  moral  insanity  is  by  far 
the  most  difficult  to  deal  with.  They  have  been 
treated  by  the  physician  whose  special  study  is  idiocy, 
as  well  as  bv  the  family  physician  and  the  jurist,  and 


Chap.  XL]  Sexual  Precocity.  273 

each  has  found  it  difficult  to  know  in  what  light  to 
look  upon  these  rtiauvais  siijets.  The  history  is  gene- 
rally of  the  following  kind  :  One  parent  almost  cer- 
tainly belongs  to  a  markedly  insane  family,  or  both 
parents  belong  to  the  same  stock,  which  is  a  degene- 
rating or  nervous  one.  The  child  has  been  an  only 
child,  the  child  of  old  age;  or  has  had  brothers  and 
sisters,  some  of  whom  have  been  deaf  and  dumb ; 
or  idiocy  or  epilepsy  has  occurred  in  the  family ;  he 
was  bright,  but  restless  and  fretful  in  infancy, 
difficult  to  amuse  or  occupy  ;  and  as  time  went  on  he 
was  characterised  by  being  peculiar ;  either  being 
bright  or  having  brilliant  special  endowments,  so  that 
he  was  perhaps  attracted  by  music  at  a  very  early 
age,  and  as  soon  as  he  could  speak  would  hum  cor- 
rectly airs  he  had  heard ;  or,  there  being  nothing- 
special  in  his  early  infancy,  it  was  first  noticed  at 
school  either  that  he  had  depraved  tastes,  or  it  was 
found  necessary  to  send  him  from  school  in  con- 
sequence of  immoral  practices,  or  because  of  thieving 
or  lying,  and  this  although  his  master  may  have  ex- 
pressed regret,  because  he  had  shown  a  special  power 
for  mathematics  or  a  wonderfully  retentive  memory. 
It  is  not  uncommon  for  children  of  this  kind  to  get 
on  moderately  well  up  to  the  age  of  puberty,  and 
then  become  utterly  unmanageable  in  consequence  of 
the  development  of  sexual  desires  and  giving  way  most 
openly  to  masturbation  ;  or,  if  boys,  making  attempts 
of  every  description  to  gratify  their  lusts  upon  children 
or  women  of  any  age.  Such  boys  expose  themselves 
indecently  and  misbehave  openly.  As  a  rule,  they 
express  contrition  at  the  time  they  are  caught  and 
threatened,  but  the  memory  of  the  punishment  never 
seems  to  be  sufficient  to  restrain  them  when  the  next 
temptation  comes.  These  patients  are  almost  invari- 
ably immoral  sexually,  and  are  the  most  cunning  of 
liars,  so  that  on  cross-examination  they  will  answer  so 
s— 14 


2  74       Insanity  and  Allied  Neuroses.    [Chap.  xt. 

rapidly  and  apparently  so  consistently  that  an  ordinary 
investigator  may  doubt  whether  there  has  not  been 
some  mistake  in  the  accusation. 

Some  of  these  cases  are  horribly  cruel,  and  others 
demoniacally  vindictive.  I  have  known  them  tor- 
ture lower  animals  which  were  unable  to  defend 
themseh^es  (for  such  patients  are  cowards)  with  red- 
hot  irons,  pins,  needles,  and  the  like,  or  by  setting  fire 
to  them  by  means  of  turpentine  or  spirit.  As  to  the 
vindictiveness  exhibited  by  such  patients,  I  was  con- 
sulted once  about  a  youth,  the  son  of  a  clergyman, 
who  was  constantly  setting  fire  to  the  houses  of  those 
with  whom  he  was  placed.  He  was,  to  all  appearances, 
an  ordinary-looking  lad,  with  a  fair  amount  of  ability, 
but  with  the  restless,  uncontrolled  nervous  instability 
common  in  these  cases.  Each  change  of  residence  was 
associated  with  temporary  amelioration,  only  to  be  fol- 
lowed by  some  coarse  or  gross  act,  which,  in  turn 
having  been  punished,  was  followed  by  some  attempt 
to  burn  the  house.  In  one  case  it  was  quite  clear  that 
a  nervous  lad  of  the  same  class,  connected  on  the  one 
hand  with  a  family  of  high  mathematical  ability  and 
on  the  other  with  nervous  instability,  was  morally  in- 
sane ;  for  a  time  being  possessed  by  the  idea  that  he 
was  injured,  he  would  make  accusations  against  people 
of  robbing  and  ill-using  him.  These  latter  symptoms 
are  those  which  require  a  few  words  of  special  refe- 
rence. Certain  persons,  probably  more  frequently 
women  than  men,  make  lying  accusations  against  per- 
sons of  the  other  sex ;  and  although  it  may  be  shown 
that  such  patients  come  of  nervous  stock,  it  will  be 
hard  to  persuade  the  public  to  let  them  off"  on  that 
plea.  Constantly  accusations,  without  the  slightest 
truth  in  them,  are  made  by  morally  insane  patients  ; 
and  those  of  us  who  have  lived  in  an  asylum  can  fully 
recognise  the  danger  which  the  outside  world  runs 
from    insane   accusations ;    especially  those    made  by 


Chap.  XL]  Sexual  Precocity.  275 

patients  wlip  are  intellectually  bright  but  morally 
perverse. 

The  intellectual  abilities  of  many  of  these  morally 
insane  people  are  striking,  but  they  are  further  evi- 
dences of  want  of  balance.  One  power,  or  one  faculty, 
seems  to  have  developed  at  the  expense  of  all  the  rest, 
and  it  is  common  to  see  precocity  in  the  morally  in- 
sane. It  may  be  sexual  precocity,  it  may  be  calcu- 
lating or  mathematical  ability  of  a  certain  kind, 
or  a  taste  for  and  power  of  reproducing  music ; 
and,  alone  or  combined  with  either  or  all  of 
the  above  powers,  there  may  be  a  memory  of  the 
most  marvellous  definiteness  and  clearness,  so  that 
dates  especially  are  recollected  with  wonderful  pre- 
cision. 

The  picture  here  given  and  the  examples,  show  one 
of  th©  most  difficult  and  dangerous  groups  of  insane 
patients.  The  patients,  from  their  intellectual  ability, 
completely  upset  the  conventional  ideas  of  insanity, 
and  the  presence  of  superior  powers  of  mind  with 
good  memory  seems  to  assure  the  ordinary  observer 
that  the  acts,  vicious  or  criminal,  which  have  been 
perpetrated,  must  have  been  performed  by  a  respon- 
sible person.  In  some  cases  the  physiognomy  of  the 
patient  is  in  his  favour. 

What  is  to  be  done  with  such  cases  %  To  begin 
with,  doubtless,  the  offspring  of  insane  parents,  or 
children  with  certain  peculiarities  of  mind  and  body, 
require  special  education.  Some  of  these  patients  are 
sent  with  benefit  to  asylums  for  idiots,  but  I  am 
inclined  to  believe  that  they  require  careful  individual 
training ;  and  that  with  this  continued  from  the  age 
of  four  or  five  up  to  twenty,  a  certain  number  may  be 
saved  from  perpetrating  criminal  acts.  It  is  not  well, 
either,  to  over-stimulate  any  intellectual  powers  they 
possess,  nor  is  it  well  to  attempt  to  suppress  them. 
Let  the  musical  faculty  be  developed  in  a  methodical 


276       Insanity  and  Allied  Neuroses.  [Chap.  xn. 

way;  but  let  a  fair,  yet  not  an  exhausting,  amount 
of  care  be  devoted  to  memory  and  matliematics, 
and  let  outdoor  exercise  and  gymnastics  be  culti- 
vated. Every  tendency  to  excitement  should  be 
avoided,  and  for  the  sake  of  other  children  the  most 
careful  isolation  and  supervision  at  night  is  necessary  ; 
but,  with  al]  this  care,  the  result  in  most  cases  will  be 
unsatisfactory. 


CHAPTER  XII. 

GENERAL    PARALYSIS    OF   THE    INSANE. 

General  i^aralysis  of  the  insane  —  General  paralysis  without 
insanity  —  Nature  of  general  paralysis  —  Other  forms  of 
paralysis  met  with  in  asylums — Causation  :  Stages,  varie- 
ties, with  examples — Sym]ptoms  in  detail — Diagnosis — Pro- 
gnosis— Treatment. 

By  far  the  most  interesting  group  of  cases,  from  a 
scientific  point  of  view,  which  one  has  to  consider  in 
an  asylum  is  that  of  general  paralysis.  This  disease, 
unlike  many  of  the  so-called  neuroses,  has  undoubtedly 
a  physical  basis,  and,  in  my  belief,  the  keystone  of 
the  nervous  pathological  arch  is  general  paralysis. 
The  disease,  chiefly  aflecting  the  robust  middle-aged 
active -minded  man,  rapidly  destroys  everything 
human  in  him,  leaving  him  to  exist,  often  for  months 
together,  an  unconscious  automaton.  I  believe  that 
the  disease  can  only  fruitfully  be  studied  and  finally 
understood  by  subdividing  the  cases  as  much  as 
possible  into  groups  according  to  the  symptoms ; 
not  with  the  idea  that  each  subdivision  represents 
a  definite,  form  of  disease,  but  that  there  will  thus  be 
found  certain  natural  groupings  of  bodily  and  mental 
symptoms.  The  study  of  the  connection  which  will 
be  seen  to  exist  between  these  latter  will  sooner  or 


Chap.  XII.]  General  Paralysis  of  the  Insane.  277 

later  clear  up  many  points  in  the  pathology  of  the 
nervous  system,  and  will  also  add  not  a  little  to  the 
comprehension  of  mental  function. 

The  first  question  to  be  considered  is,  whether  the 
disease  called  general  paralysis  of  the  insane  deserves 
its  name,  and  whether  it  must  be  considered  as  neces- 
sarily connected  with  insanity.  One  of  the  questions 
which  general  physicians  ask  is,  whether  this  same 
disease,  which  is  called  general  paralysis,  can  exist 
without  mental  disorder.  I  always  reply  that  I  have 
seen  several  cases  who  for  years  have  exhibited 
bodily  symptoms  in  every  particular  coinciding  with 
those  found  in  the  patients  in  our  asylums  suffering 
from  general  paralysis  of  the  insane,  and  yet  without 
the  slightest  evidence  of  insanity,  even  without 
any  loss  of  memory  or  of  self-control ;  so  that,  in  fact, 
the  patient  was  sound  in  mind  although  a  general 
paralytic  in  body.  The  reason,  I  believe,  that  the 
condition  has  hitherto  been  misunderstood  is,  that 
asylum  physicians  rarely  see  cases  in  general  hospitals ; 
and  general  physicians  only  occasionally  have  the 
chance  of  watching  true  general  paralysis.  In 
my  opinion,  general  paralysis  may  develop  in  any 
of  its  forms  without  mental  symptoms  for  a  con- 
siderable length  of  time  ;  but  unless  cut  short 
by  some  inter-current  or  accidental  cause,  mental 
deterioration  shows  itself  before  the  end.  The  symp- 
toms may  be  only  those  of  weak-mindedness,  and 
may  be  so  slight  that  comparatively  little  importance 
is  attached  to  them. 

Having  thus  given  my  opinion  that  general 
paralysis  may  occur  with  few  or  no  mental  symp- 
toms, I  would  next  say  that  the  term  does  include 
various  forms  of  nervous  degeneration,  and  that,  in 
fact,  the  term  as  at  present  used  includes  several 
classes  which  will  have  to  be  subdivided  as  our  know- 
ledge increases.     Of  these  subdivisions  I  shall  have 


278      Insanity  and  Allied  Neuroses.   [Chap.xii. 

to  speak  more  fully  later;  for  I  do  not  consider 
that  the  divisions  which  have  been  made,  either  from 
the  clinical  or  pathological  side,  are  sufficiently  pre- 
cise. To  say  that  one  group  of  cases  suffers  from 
spinal  general  paralysis,  and  that  another  suffers  from 
cerebral  general  paralysis,  is  not  sufficient ;  nor  is  it 
satisfactory  to  speak  of  general  paralysis  in  men, 
general  paralysis  in  women,  and  general  paralysis  in 
old  people.  It  will  be  found  impossible  satisfactorily 
to  divide  the  cases  according  to  the  condition  of  the 
brain  as  found  after  death.  The  disease  is  general 
in  its  cause  and  its  effect,  and  in  the  brain  we  only 
take  into  consideration  one  of  the  factors  of  the 
disease.  The  best  divisions,  to  my  mind  (because  they 
are  both  clinical  and  pathological),  are  those  made  by 
Dr.  Julius  Mickle,  and  I  shall  have  to  refer  to  his 
excellent  monograph  in  detail  again. 

I  believe,  then,  that  several  distinct  varieties 
of  general  paralysis  exist,  or  rather  that  several 
distinct  series  of  changes  occur  in  the  nervous 
centres,  giving  rise  to  a  progressive  and  fatal 
nervous  disease,  which  has  been  called  general  para- 
lysis. I  can  hardly  be  expected,  therefore,  to  say 
that  I  believe  general  paralysis  to  be  a  definite  and 
specific  disease.  I  am  in  the  habit  of  saying  that,  in 
my  experience,  any  conditions  which  may  start  a 
progressive  decay  of  the  higher  nervous  tissues  will 
give  rise  to  symptoms  resembling  those  which  have 
been  classified  as  general  paralysis  ;  that  we  have  in 
such  a  diseased  condition  a  gradual  destruction  of 
nerve  centres.  Moreover,  it  may  be  purely  a 
matter  of  accident  whether  this  be  due  in  the  first 
place  to  premature  disease  of  arteries,  or  to  mal-nutri- 
tion  associated  with  constant  strain  ;  imperfect  rest, 
and  regeneration  of  the  nerve  tissues ;  or  whether, 
again,  it  be  due  to  changes  in  the  relations  between 
brain  and  vessels  following  injury  or  inflammation. 


Chap.  XII.]      Progressive  Degeneration.  279 

That  the  disease  is  progressive  is  without  contradic- 
tion ;  that  it  rarely  affects  a  large  part  of  the  brain 
or  nervous  systems  suddenly  is  also  a  fact ;  that  its 
action,  whether  upon  the  brain  or  cord,  is  very  small 
and  hard  to  be  detected  at  first,  I  also  believe  ;  that 
it  affects  first  the  highest  intellectual  and  motor 
acquirements  is  undoubted.  Both  Dr.  Maudsley  and 
I  have  independently  taught  that  in  this  progressive 
degeneration  the  last  and  highest  acquirements  fail 
first,  so  that  the  musician  loses  his  power  over  his 
fingers,  the  seamstress  can  no  longer  sew,  the  dan^ 
sense  fails  in  her  ikis,  and  the  actress  blurs  her  phrases 
and  forgets  her  part.  This  effacement  of  the  highest 
acquirements  will  be  seen  to  be  associated  with  the 
loss  of  self-control,  and,  in  fact,  the  patient  passes 
from  his  normal  condition  into  a  state  as  nearly  as 
possible  identical  with  that  produced  by  mild  alcohol- 
ism ;  and  at  least  in  one  case  I  have  been  able  to 
ascertain  that  the  early  symptoms  of  general  paralysis 
resembled  exactly  those  produced  in  the  same  patient 
when  partly  intoxicated.  From  the  above  I  infer 
that  the  degeneration  is  one  generally  beginning  in 
the  highest  and  last  organised  parts  of  the  nervous 
tissues,  and  that  as  it  spreads  it  produces  more  and 
more  marked  signs  of  degeneration.  The  rapidity 
of  degeneration,  the  amount  of  mental  loss  in  a  given 
time,  differs  in  each  case.  Why  this  disease  should 
specially  affect  men ;  why  it  should  affect  to^vnsmen 
and  men  leading  active  industrious  lives,  men,  as  a 
rule,  of  good  physique  and  active  temperament,  I 
cannot  explain.  The  disease  is  special,  in  so  far 
that  it  ends  fatally  in  nearly  all  cases,  and  in  almost 
always  the  same  way ;  and  that,  whatever  the  earlier 
symptoms  may  have  been,  the  later  ones  are  similar 
to  a  remarkable  degree. 

It   must    be    remembered    that    in    an    asylum 
other  forms  of  paralysis  occur.     In  Bethlem  I  have 


28o      Insanity  AND  Allied  Neuroses.  [Chap.  xii. 

seen  examples  of  almost  every  known  variety  of  para- 
lysis occurring  quite  independently  of  any  symj)toms 
which  would  incline  one  to  suspect  general  paralysis. 
We  have  ordinary  hemiplegia,  paraplegia,  dissemi- 
nated sclerosis,  locomotor  ataxy,  and  bulbar  paralysis, 
but  these  are  not  to  be  mistaken  for  the  cases  of 
general  paralysis  of  the  insane. 

I  have  said  that  general  paralysis  may  occur  in 
the  sane,  and  I  would  here  refer  to  several  cases  about 
which  I  have  been  consulted.  The  first  is  that  of  a 
married  man,  aged  thirty-eight  (no  insanity  in  his 
family),  who  had  led  an  active,  industrious  life.  He 
came  to  see  me  in  consequence  of  change  in  his  hand- 
writing and  hesitation  of  speech.  When  I  examined 
him  I  found  that  his  pupils  were  unequal,  his 
tongue  tremulous,  his  hand-writing  shaky,  with  a 
tendency  to  drop  terminal  letters  of  words.  There 
was  a  greatly  increased  patella  reflex  ;  yet  with 
all  these  bodily  symptoms  I  could  detect  no  change  in 
his  mental  capacity  whatever.  His  memory  was 
good ;  he  was  not  emotional ;  nor  had  he  lost  any 
power  of  self-control.  This  patient  has  for  years  been 
under  my  observation,  and  has  shown  no  intellectual 
disturbance  whatever,  and  at  the  present  time  I 
believe  he  is  earning  his  living.  The  end  will  pro- 
bably be  weak-mindedness,  but  at  present  there  are 
no  points  to  guide  one  as  to  when  it  is  going  to 
develop.  Constantly  I  am  called  upon  to  see  cases 
in  general  hospitals,  in  which  the  bodily  symptoms 
are  marked,  while  the  mental  ones  are  absent,  or  very 
slight.  In  some  cases  the  bodily  symptoms  are  only 
prematurely  developed,  or  out  of  relation  to  the 
mental  ones,  either  occurring  much  more  markedly  than 
is  usual  in  the  earlier  stages,  while  the  mental  symp- 
toms are  slight ;  or  the  bodily  symptoms  may  appear 
to  be  followed  in  a  short  time  by  the  mental  ones. 

In  the  following  case  the  mental  symptoms  were 


Chap.  XII.]  Causation  OF  General  Paralysis.    28 i 

extremely  slight,  altlioiigh  the  bodily  signs  were 
distinct  enough  :  A  married  man,  set.  forty,  had  been 
for  many  years  in  the  Custom  House,  and  had  a 
very  keen  delight  in  self-culture.  He  was  one  of 
the  typical  Englishmen  of  the  middle  classes,  who 
devote  every  spare  moment  to  improving  their  minds. 
He  told  me  that  since  boyhood  he  had  been  accus- 
tomed to  carry  about  with  him  manuals  of  one  science 
or  another,  foreign  grammars,  or  other  means  of  general 
education.  He  took  little  exercise,  refrained  from  all 
stimulants,  and  led  what  might  be  called  an  exemplary 
life.  Six  or  seven  months  before  he  came  to  see  me, 
he  tottered  in  his  walk,  and  noticed  that  his  hand- 
writing was  changing  in  its  character,  and  that  he 
was  no  longer  able  to  do  the  clerical  work  which  was 
expected  of  him.  When  he  first  visited  me  he  at 
once  pointed  to  his  head,  and  said  that,  like  Swift,  he 
was  "  going  first  at  the  top,"  and  for  a  moment  he 
appeared  emotional,  but  by  carefully  avoiding  refe- 
rence to  his  physical  weakness,  he  was  induced  to 
speak  of  his  powers  and  abilities  with  considerable 
personal  satisfaction.  Since  then  I  have  seen  him 
several  times,  and  find  that  his  muscular  power  is 
lessening,  that  he  is  ataxic  in  walk,  with  absence  of 
patella  reflex,  and  that  there  is  a  general  feeling  of  hien 
etre  quite  out  of  accord  with  his  physical  condition. 
In  this  case  the  bodily  symptoms  are  much  more  pro- 
nounced than  are  the  mental  ones,  but  I  have  no 
doubt  of  the  nature  of  the  case,  and  the  certainty  of 
its  unfavourable  termination.  Many  other  such  cases 
are  seen  by  me  every  year,  but  the  examples  I  have 
given  must  suffice. 

Causation  of  general  paralysis. — It  will 
be  convenient  to  consider  causation  under  one  general 
heading,  making  no  distinction  between  the  groups  of 
cases  to  which  I  have  already  referred,  although  I  am 
sure  it  will  be  found  that  certain  cases^  depending  on 


2«2 


Insanity  and  Allied  Neuroses.    [Chap.  xii. 


special  causes  for  their  origin,  have  special  modes  of 
development,  and  manifest  corresponding  peculiarities 
in  the  symptoms.  For  example,  traumatic  general 
paralysis  may  differ  essentially  from  that  produced  by 
alcoholism,  and  this  again  from  that  due  to  syphilis  ; 
however^  it  will  be  advisable  for  the  present  to  avoid 
any  particular  differentiation  of  the  causation,  leaving 
this  to  a  later  stage,  w^hen  we  shall  have  before  us 
all  the  symptoms.  I  will  first  consider  the  causation 
generally,  as  if  the  disease  were  a  specific  one. 

The  favourite  idea  in  England  at  present  is  that 
general  paralysis  depends  upon  sexual  excess^  and  Dr. 
Maudsley  has  done  much  to  establish  this  belief. 
Undoubtedly  sexual  excess  may  be  a  cause  of  general 
paralysis ;  it  is  certainly  a  very  exhausting  cause,  but 
such  excess  is  difficult  to  determine,  for  I  suppose  it  is 
rare  to  find  two  individuals  who  are  similarly  liable  to 
exhaustion  from  this  or  any  one  cause.  Just  as  a 
slight  alcoholic  indulgence  will  produce  intoxication 
with  one,  whilst  another  may  require  an  enormous 
amount  of  alcohol  to  affect  him  ;  so  with  sexual  in- 
dulgence, what  is  excess  in  one  is  moderation  in 
another.  There  are  patients  admitted  yearly  into 
Bethlem  whose  disease  I  believe  to  be  chiefly  pro- 
duced by  sexual  excess  ;  but  such  men  are  generally 
not  only  living  lives  of  general  excitement,  but  are 
wedded  to  women  of  a  specially  amatory  nature  j  and 
although  it  would  be  unscientific  to  connote  excess  as 
necessarily  associated  with  certain  types  of  women,  I 
have  been  struck  by  the  frequency  of  the  occurrence 
of  general  paralysis  in  the  husbands  of  some  women  of 
voluptuous  physique.  Again,  as  with  other  disorders 
of  the  mind,  it  is  often  difficult  to  distinguish  between 
early  symptoms  and  causes.  Undoubtedly  sexual 
excess  may  have  something  to  do  with  the  production 
of  general  paralysis,  but  there  is  no  doubt  that  sexual 
excess  is  a  common  early  symptom  of  the  disease.^     I 


Chap.  XII. 1  Anxiety  and  General  Paralysis.    283 

am  quite  sure  I  have  been  able  to  eliminate  sexual 
excess  from  a  considerable  number  of  cases  wliich 
have  come  under  my  notice,  especially  among  women. 

Masturbation,  in  my  experience,  very  rarely  gives 
rise  to  any  symptoms  like  those  of  general  paralysis  of 
the  insane, 

A  lcoholis7n  is  also  a  recognised  cause  of  mental  de- 
generation, and  alone  or  combined  with  other  excesses 
and  injuries  is,  to  my  mind,  an  undoubted  cause  of  the 
disease. 

Syphilis,  which  is  supposed  to  play  such  an  im- 
portant role  in  most  nervous  disorders,  especially  those 
of  an  intricate  kind,  has  also  been  credited  with  the 
production  of  a  large  amount  of  general  paralysis. 
And  here,  again,  I  must  say  that  I  have  had  cases 
under  observation  in  which  the  progressive  mental 
and  bodily  degenerations  had  to  be  classified  as  be- 
longing distinctly  to  general  paralysis,  on  the  one 
hand,  and  on  the  other  were  as  distinctly  due  to  syphilis. 
When  considering  the  pathology  of  the  disease,  I  shall 
refer  to  cases  in  which  there  have  been  found  after  death 
local  syphilitic  changes  that  have  given  rise  to  S3nnp- 
toms  indistinguishable  from  those  of  general  paralysis. 

Injiiry  also  must  be  credited  with  the  causation  of 
a  certain  number  of  cases,  and  probably  most  of  those 
which  are  seen  in  general  hospitals,  and  which  have 
but  little  mental  derangement,  are  those  which  follow 
injury. 

The  above  are  the  chief  physical  causes,  and  on 
the  moral  side  I  would  place,  first  of  all,  anxiety.  I  do 
not  look  upon  general  paralysis  as  the  disease  of  over- 
work, and  although  it  seems  steadily  to  increase  with 
the  increase  of  civilisation  and  with  higher  education, 
and  although  it  appears  now  among  women  who 
are  struggling  to  take  the  places  of  men,  yet  my  ex- 
perience is  that  the  relationship  is  not  with  work, 
but  with  worry.     General  paralysis  occurs  mostly  in 


284      Insanity  and  Allied  Neuroses.  [Chap.  xii. 

the  anxious-minded,  conscientious  man,  and  as  far  as 
my  experience  among  the  middle-classes  is  con- 
cerned it  is  rather  due  to  over-strain  than  over- 
work. Many  examples  occur  in  which  the  struggling 
man  manifests  symptoms  of  general  paralysis  just 
when  success  appears  to  have  been  achieved,  and 
I  have  seen  several  cases  in  which  the  insanity 
and  break-down  were  attributed  to  retirement  from 
active  business,  whereas  the  truth  was  that  the 
over-strain  which  had  secured  a  fortune  had  left 
the  man  a  wreck.  Anxiety  about  business  matters 
seems  to  be  most  disastrous.  Occasionally  one 
meets  with  cases  in  which  the  disease  has  been 
started  by  domestic  unhappiness,  but  these,  as 
I  say,  are  less  common.  Some  little  time  ago  a 
patient  was  admitted  into  Bethlem  suffering  from  this 
disease,  and  I  have  no  doubt  it  was  produced  in  the 
following  way  :  The  man,  an  energetic  manager  of  a 
successful  business,  prosecuted  some  workmen  under 
him  for  want  of  performance  of  their  duties  j  he 
failed  to  get  a  conviction  through  a  conspiracy  of 
the  workmen,  and  the  result  was  that  his  life  was 
rendered  miserable  by  a  system  of  threatening  and 
intimidation.  Sleeplessness,  worry,  and  loss  of  appe- 
tite were  followed  by  the  ordinary  signs  of  general 
paralysis  of  the  insane.  To  sum  up,  general  paralysis 
usually  arises  from  a  combination  of  causes ;  the 
most  common  direct  causes  being  excesses  of  all 
kinds,  whether  sexual  or  alcoholic,  which  act  more 
powerfully  when  associated  wdth  strain,  worry,  and 
anxiety ;  and,  finally,  we  see  that  physical  injuries 
may  also  produce  the  disease,  as  may  also  such  phy- 
sical diseases  as  syphilis,  etc. 

Varieties  of  general  paralysis  of  the 
insane. — Under  this  heading  I  shall  consider,  first, 
the  various  forms  of  mental  andbodily  disorder,  which 
are  classed  as  general  paralysis.     Undoubtedly  there 


Chap. XII. I  Varieties  of  General  Paralysis.     285 

are  some  natural  and  some  artificial  divisions,  and  tlio 
wliole  arrangement  must  be  considered  as  a  provisional 
one,  I  shall  divide  tlie  cases,  first  into  acute  and 
chronic;  then  into  those  in  which  the  symptoms  are 
'primarily  maniacal^  with  exaltation  of  ideas  :  next 
the  melancholic  and  hypochondriacal  cases  ;  and,  lastly, 
those  in  which  dementia  is  more  or  less  pronounced 
from  the  onset.  It  will  be  seen  in  tracing  the  history 
of  cases  that  they  nearly  all  end  in  dementia  sooner 
or  later.  In  the  next  division  I  shall  consider  whether 
the  hrain  or  cord  symptoms  are  most  marked,  or  come 
on  earliest;  and  when  considering  the  latter  I  shall 
divide  the  cases  into  those  in  which  the  j)osterior 
coho7nns  of  the  cord  are  most  affected,  and  those  in 
which  the  lateral  columns  are  chiefly  involved.  In 
considering  cases  I  shall  discuss  the  various  symptoms 
which  may  occur,  and  later  exemplify  the  symptoms 
by  means  of  typical  cases. 

Dr.  Mickle  has  described  five  groups  of  general 
paralysis,  pathologically  and  clinically. 

Undoubtedly  there  is  a  series  of  pathological 
changes  connected  with  each  definite  group  of  clinical 
symptoms,  but  a  great  deal  remains  to  be  done  to 
associate  these. 

Besides  ordinary  cases  of  general  paralysis,  one 
meets  with  numerous  cases  in  which  there  is  some 
slight  peculiarity,  either  as  to  the  causation  or  course 
of  the  disease  ;  or  one  or  more  of  the  syaiptoms  may 
be  unduly  prominent ;  or  symptoms  which  rarely 
occur  may  from  time  to  time  present  themselves. 
Thus,  although  it  is  rare  to  meet  with  strabismus  or 
ptosis  in  general  paralysis,  they  do  at  times  occur ; 
and  although  fits  are  usual,  yet  the  disease  may  run 
its  course  without  their  presence.  General  paralysis 
may  follow  upon  some  local  disease  ;  and  just  as  I  have 
seen  symptoms  of  general  paralysis  develop  on  old 
locomotor  ataxy,  so  I  have  seen  it  occur  in  cases  which 


286       Insanity  AND  Allied  Neuroses.  [Chap.  xii. 

have  suffered  from  some  other  nervous  lesion,  such  as 
the  paralysis  of  childhood.  The  special  points  of 
pathology  and  diagnosis  will  be  considered  towards 
the  end  of  this  chapter. 

Stag^es  ill  tlie  course  of  general  paralysis 
of  the  insane. — The  greatest  medical  importance 
still  attaches  to  the  very  earliest  stages  of  this  disease, 
for  if  any  good  is  to  be  done,  it  must  be  done  early, 
before  any  well-marked  symptoms,  evidences  of  real 
degeneration,  have  shown  themselves. 

It  is  still  very  difficult  to  give  any  distinct 
answer  to  the  question  as  to  the  length  of  time  the 
warning  symptoms  may  precede  the  evident  signs  of 
the  disease.  Generally  after  the  disease  has  made 
itself  evident,  or  after  the  death  of  the  patient,  the 
friends  will  give  further  details  which  may  enable  one 
to  trace  the  first  steps  in  the  morbid  process. 

I  shall  briefly  refer  to  the  warning  or  prodronfial 
symptoms  first,  and  next  consider  the  initial  symptoms. 
The  'prodromal  symptoms  may  be  either  bodily  or 
mental,  or  both. 

The  bodily  symiotoms  are  generally  some  degree  of 
paralysis.  Thus  the  wife  of  one  patient  now  in  Beth- 
lem  noticed  temporary  loss  of  speech,  followed  by 
hesitation  and  tremor,  nearly  eight  years  before  she 
suspected  that  any  serious  disease  was  imminent. 
The  attacks  of  aphasia  recurred  at  intervals,  and 
when  it  was  necessary  to  send  the  patient  to  an 
asylum,  the  difficulty  of  speech  and  tremor  of  tongue 
and  lips  were  very  much  marked. 

In  other  cases,  giddiness  or  attacks  of  vomiting- 
may  precede  the  disease.  Loss  of  power  in  the  lower 
extremities,  too,  is  not  uncommon,  so  that  the  history 
will  be  given  of  a  fall  as  the  cause  of  illness,  whereas 
the  fall  was  the  earliest  result  of  nervous  change. 

Locomotor  ataxy,  or  some  other  form  of  paralysis, 
may  exist  long  before  general  paralysis  is  detected. 


Chap.  XII.]  Mental  Symptoms.  287 

Headache,  or  pains  in  the  head  of  a  variable  kind, 
may  be  noticed.  Slight  convulsions  may  have  occurred, 
and  may  have  been  recovered  from  and  forgotten, 
till  the  general  paralysis  shows  itself  many  years 
afterwards. 

On  the  mental  side  there  may  have  been  noticed 
some  moral  or  intellectual  change,  slowly  or  quickly 
changing  the  whole  nature  of  the  man. 

In  one  case  the  patient  had,  for  two  years  before 
he  was  suspected  of  illness,  been  guilty  of  mean  acts 
and  fraudulent  appropriation  of  property. 

These  acts  were  done  with  great  caution,  and  with 
evident  knowledge  of  the  nature  of  the  act  and  the 
liability  attached,  yet  he  ought  not  to  be  considered 
fully  responsible. 

Intemperance  in  drink,  or  in  any  other  respect, 
may  be  the  warning,  and  I  have  known  a  return  to 
uxoriousness,  or  a  development  of  jealousy  or  strong 
family  affection,  precede  the  outbreak  of  general 
paralysis. 

Irritability,  restlessness,  broken  sleep,  or  drowsi- 
ness, especially  after  meals,  may  also  be  noteworthy. 

Loss  of  memory  for  recent  matters,  for  facts  not  for 
dates,  names,  or  other  abstract  details,  may  occur. 
Complaints  of  loss  of  power  and  a  kind  of  mental 
hypochondriasis  may  also  serve  as  a  warning.  I  have 
known  more  than  one  man  who  has  told  me  that  he 
was  sure  he  was  going  mad ;  and  in  one  case  a  doctor 
told  me  he  was  suffering  from  this  disease,  though 
after  telling  me  this  he  neglected  his  own  diagnosis 
and  began  to  talk  freely  of  his  patients.  He  died 
eight  years  later  of  general  paralysis. 

I  am  always  guarded  in  my  prognosis  when  a 
strong,  middle-aged  man,  not  of  a  neurotic  family, 
consults  me  for  vague  and  variable  nervous  symptoms. 

In  such  cases,  I  insist  on  the  danger  there  may 
be,  and  advise  abstention  from  business,  from  domestic 


288      Insanity  and  Allied  Neuroses.  [Chap.  xii. 

and  social  engagements.  I  often  say  that  if  men  in 
this  stao'e  or  condition  could  be  made  to  treat  their  life 
like  a  piece  of  music,  and  keep  fixed  intervals  of  rest 
between  the  notes  of  action,  they  might  stop  the 
disease. 

In  a  steadily  progressive  disease  it  is  impossible  to 
make  clear  distinctions  between  the  stages  ;  and  it 
must  be  admitted  that  the  initial  stage  is  one  about 
which  each  author  differs.  For  my  part,  I  look  upon 
the  "  initial  stage  "  as  equivalent  to  the  first  noticed 
symptom,  there  being  no  break  between  its  appear- 
ance and  the  recognition  of  a  disordered  or  diseased 
state.  The  initial  stage,  or  first  symptom,  may  be 
one  act  or  one  symjotom,  or  it  may  be  a  group  of 
symptoms  or  series  of  acts  ;  it  may  be  motor ^ 
sensory,  or  mental. 

Probably  tremor  of  tongue,  clipping  of  words,  or 
some  slight  change  in  gait,  are  the  most  common 
initial  symptoms.  A  convulsion  may  start  the  process. 
Change  in  feeling,  possibly  loss  of  power  of  smell,  or 
local  ansesthesia,  or  slight  perversion  of  sight,  such  as 
colour  blindness,  may  occur. 

Hypochondriasis  may  also  be  a  first  symptom. 

On  the  mental  side,  emotional  disturbances,  passion, 
restlessness,  lust,  extravagance,  and  loss  of  memory  are 
the  most  common  heralds  of  disease. 

There  is  nothing  special  either  in  the  prodromal  or 
in  the  initial  symptoms  of  the  disease,  and  there  is  no 
possibility  of  saying  what  will  be  the  duration  and 
course  of  the  disease  from  the  earlier  symptoms.  Some 
patients  who  begin  with  excitement  become  melan- 
choly, and  more  who  are  first  depressed  become  excited. 
In  one  case,  quiet  dementia,  which  had  lasted  for 
eighteen  months,  was  followed  without  warning  by  a 
most  violent  outbreak  of  maniacal  excitement.  As  a 
rule,  from  the  early  symptoms  one  may  judge  whether 
the  case  will  be  one  of  so-called  spinal  or  cerebral 


Chap.  XII.]  General  Paralysis.  289 

general  paralysis,  and  again  wlietlier  the  disease  will  be 
of  tlie  tabetic  or  tlie  lateral  sclerotic  type. 

Again,  the  prognosis  is  worse  if  convulsions  were 
the  starting-point. 

General  Paralysis  of  the  Insane. 

First  stage. — Mania,  melancholia,  dementia,  con- 
vulsions, commonly  lead  to  the 

Second  stage,  which  in  all  varieties  tends  to 
dementia.  Loss  of  control  of  rectum  and  bladder 
marks  the 

Third  stage  of  marked  dementia. 

The  first  stage. Oti  general  paralysis  of  the  uisane  is 
very  variable,  and  I  believe  at  present  we  have  no 
means  of  judging  of  its  probable  duration.  It  may 
conveniently  be  taken  to  begin  with  the  period  when 
the  disorder  is  such  that  the  question  of  special  treat- 
ment is  considered.  This  stage,  having  begun  in  any 
of  the  ways  I  have  already  described,  may,  in  its  turn, 
be  a  steady,  progressive  development  of  the  initial 
symptoms,  or  a  reaction  from  them  ;  the  case  which 
begins  in  a  worn-out  man  with  weak-mindedness  will 
probably  continue  to  exhibit  weakness  of  mind  as 
the  chief  symptom ;  speaking  generally,  in  the  iirst 
stage  the  most  common  of  all  conditions  is  that  of 
mobility  and  changeableness. 

If  the  patient  after  a  short  period  of  mental  de- 
pression passes  slowly  or  rapidly  into  a  state  of  exalta- 
tion, the  steps  are  probably  the  following :  Re- 
covering from  his  depression,  he  becomes  restless  and 
energetic,  and  passes  into  what  I  call  the  changing 
or  reforming  stage.  He  is  not  contented  with  his 
house  or  his  business ;  he  is  irritable,  and  if  op- 
posed loses  all  self-control  for  a  time  ;  his  constant 
restless  and  only  half -completed  plans  distress  and 
annoy  those  near  him.  He  is  often  sleepless,  or, 
at  any  rate,  he  gets  up  very  early,  and  says  he  has 
T — 14 


290         Insanity  and  Allied  Neuroses.  [Chap.  xii. 

found  that  hitherto  he  has  slept  too  much.  He  is  at 
times  destructive,  or,  as  he  thinks,  constructive,  tearing 
up  books  to  rearrange  them.  He  may  determine  to 
change  his  profession,  or  he  may  seek  out  royalty  or 
politicians  to  instruct  them  in  their  duties. 

Telegraphing,  sending  endless  post-cards,  and  hiring 
cabs  are  common  symptoms. 

The  purchase  of  useless  articles  in  large  numbers 
is  also  characteristic.  A  man  who  buys  a  dozen 
broughams  and  twenty  parrots  is  probably  a  general 
paralytic.  A  patient  in  the  early  stage  may  deter- 
mine to  do  some  benevolent  act,  or  may  ruin  himself 
as  a  champion  of  some  craze.  Any  symptom  which  is 
met  with  in  early  stages  of  intoxication  may  be  pre- 
sent :  one  man  boasting  of  his  ancestors,  a  second  of  his 
strength,  a  third  swearing  friendship  to  a  lacquey,  a 
fourth  boasting  of  his  amours  and  maundering  senti- 
mental ballads,  while  another  is  bathed  in  tears  of 
sympathy,  and  others  again  being  reduced  to  simple 
drunken  folly. 

The  effect  produced  by  drink  may  foreshadow  what 
the  same  man  would  do  when  he  is  in  the  early  stage 
of  general  paralysis.  Restlessness,  to  my  mind,  is  the 
most  general  symptom  :  one  man  never  ceasing  to  walk 
as  if  for  a  perpetual  walking  match ;  another  filling 
every  piece  of  paper  he  can  steal  or  borrow  with 
badly-written  letters ;  another  violently  playing  any 
game  he  can  get  at ;  and  others  painting,  singing, 
and  talking  without  ceasing. 

The  memory  may  fail  a  little  in  this  stage,  and  the 
will  is  not  firm,  so  that  the  patient  is  easily  led ;  the 
association  of  ideas  is  good,  as  a  rule.  Hallucinations 
may  occur  ;  but  I  find  it  difficult  to  be  sure  of  the 
number  and  variety  of  these  as  seen  in  general  para- 
lysis. Such  a  patient  is  glad  to  own  that  God  talks 
to  him,  or  that  beautiful  female  angels  appear  to  him; 
but  I  find  that  such  patients  rarely  spontaneously  talk 


Chap.  XII.]  Organic  Functions.  291 

of  voices  or  of  visions.  Smell  of  pepper  may  oe  lost, 
as  Yoisin  has  said ;  but  this  is  very  rare  in  my  ex- 
perience, and  is  associated  with  other  losses  of  sen- 
sibility. 

There  is  rarely  hypersesthesia,  while  local  anaesthesia 
is  more  common. 

There  may  be  alteration  in  the  reflexes.  The  skin 
assumes  one  of  several  aspects  :  it  may  be  like  that  of 
the  beer-drinker,  in  one  case  swollen,  expressionless, 
and  flabby,  with  a  greasiness,  especially  on  forehead, 
and  about  aloe,  nasi ;  or  it  may  resemble  that  of  the 
spirit-drinker,  being  sallow,  thin,  dry,  and  with  vascu- 
larity over  the  malar  bones.  In  some  cases  a  specially 
anaemic  look  is  present,  the  patient  having  a 
tallowy  aspect  of  a  very  special  nature  ;  yet  I  have 
failed  to  find  any  particular  blood  changes  in  such 
cases.  The  hair,  which  is  generally  abundant,  may 
become  grey. 

Changes  in  the  eyebrows  and  eyelashes  have  been 
described  ;  a  kind  of  weeping  of  the  latter  has  been 
pointed  out ;    but  I  do  not  think  it  is  of  much  value. 

The  pupils  are  frequently  unequal,  and  may  be 
eccentric  or  irregular.  Sight  is  rarely  aflected ;  and, 
in  my  experience,  it  is  rare  to  find  any  changes  in 
the  optic  discs  ;  ptosis  or  strabismus  is  rare. 

Next,  as  to  the  organic  functions. 

After  the  first,  when  the  appetite  may  be  small, 
and  the  tongue  furred,  the  appetite  is  very  good,  and 
the  patient  accepts  all  he  has  given  him  as  the  very 
best. 

His  bowels  are  fairly  regular;  but  there  is,  in 
some,  constipation. 

Sexual  passion  is  strong ;  but  power  is  often  defi- 
cient.     Sexual  excess  and  masturbation  are  common. 

The  breathing  and  heart's  action  are  normal,  as  a 
rule,  though  I  have  febrile  pulse-tracings  in  some  early 
cases  with  excitement.    Sleep,  which  was  not  profound, 


292         Insanity  AND  Allied  Neuroses.  [Chap.  xii. 

becomes  more  and  more  deep  and  satisfactory.  Dreams 
of  a  pleasant  type  are  common. 

The  bodily  weight  is  rapidly  increased. 

The  muscles  are  well  nourished,  and,  save  in  spinal 
cases,  the  gait  is  good. 

The  muscles  react  normally  to  the  electrical  stimuli ; 
in  a  few  cases  they  are  unduly  excitable,  or  certain 
groups  of  muscles  show  some  slight  changes 

The  tongue  is  tremulous,  being  put  out  un- 
certainly. 

The  handwriting  is  becoming  shaky,  and  letters 
are  being  dropped. 

The  patient  has  lost  his  highest  muscular  powers, 
so  that  the  musician  fails  with  his  fingers,  and  the 
danseuse  with  her  feet.  The  actor  plays  false,  and  the 
clerk  mis-spells. 

The  temperature  may  be  normal,  or,  in  certain 
cases,  vary  from  100*^  in  the  morning  to  102*^  at 
night. 

The  urine  is  very  variable  in  quantity  and  quality. 

The  first  stage  may  impercejotihly  pass  into  the 
second,  or  a  fit  may  be  the  dividing  mark.  This  fit 
may  be  of  a  very  variable  nature.  In  one  patient  a 
slight  twitch  is  seen  to  pass  over  the  face,  pallor  occurs, 
and  in  a  minute  the  patient  recovers,  wondering  what 
is  the  matter,  and  why  others  look  at  him.  A  simple 
attack  of  bilious  vomiting  may  represent  the  fit,  or 
there  may  be  a  series  of  fits  of  the  most  violent  kind, 
keeping  the  patient  unconscious  and  in  a  status  epilep- 
ticus  for  days.  The  fits  may  be  general,  or  may  affect 
but  one  side  j  they  may  resemble  ordinary  epilepsy  or 
apoplexy. 

After  recovery  of  consciousness  there  is  a  period  of 
confusion,  which  may  last  a  few  days ;  but  any  hemi- 
plegia is  soon  recovered  from,  thus  distinguishing  the 
fits  from  those  of  apoplexy. 

After   the   fit   a  marked  mental  deterioration  is 


Chap.  XII.]     Second  Stage  of  Paralysis.  293 

noticed ;  often  the  patients  become  careless  in  their 
dress  and  gross  in  their  appetites.  The  fits  may  kill 
at  once,  or  may  recur  at  irregular  intervals,  generally 
following  a  similar  course  in  each  attack. 

The  fits  may  leave  aphasia. 

The  memory  fails,  and  though  some  cases  appear  to 
regain  even  their  old  ideas  of  grandeur,  they  are 
found  to  be  much  more  manageable.  In  the  second 
stage  of  confirmed  general  paralysis  all  the  muscular 
and  mental  symptoms  exhibit  marked  increase  of 
weakness ;  and,  as  the  first  stage  might  be  called  one 
of  loss  of  control,  this  may  be  said  to  be  one  of  loss 
of  power. 

The  most  marked  symptoms  now  are  loss  of  facial 
expression;  generally,  but  not  always,  increase  of 
tremor  of  lips  and  tongue.  The  speech  is  more  hesi- 
tating ;  words  like  ''artillery"  are  badly  pronounced, 
and  the  voice  may  become  changed  and  monotonous. 
The  gait  becomes  more  or  less  affected,  and  the 
restlessness  is  less.  The  appetite  is  good,  but 
the  food  is  often  badly  masticated,  and  may  be  swal- 
lowed with  difiiculty.  At  this  stage  there  may  appear 
some  peculiar  habits,  such  as  that  of  constantly  swal- 
lowing, or  of  movements  of  the  lower  jaw ;  and 
grinding  of  the  teeth  may  also  show  itself.  This  last 
symptom  is  a  very  common  one,  and  may  go  on  for 
months,  in  some  cases  the  teeth  being  worn  down  or 
even  broken  ofi!  Common  sensibility  is  often  lost, 
the  changes  in  the  reflexes  more  marked,  the  pupils 
are  more  constantly  unequal,  and  some  changes  may 
be  visible  in  the  discs;  these  are  simple  hypersemia 
or  tendency  to  atrophy.  The  patient  may  have  a 
complete  remission  for  a  time,  or  may  improve  to  a 
great  extent. 

In  some  cases  the  whole  character  of  the  disease 
changes:  one  patient,  who  had  before  been  obstinate 
and   hypochondriacal,  becoming,  after  a  fit,  fat  and 


294         Insanity  and  Allied  Neuroses.  LChap.  xti. 

jolly,  and  another  becoming  deeply  emotional  or 
melancholic. 

Skin  changes  may  also  occur,  so  that  a  patient 
may  have  livid  extremities,  or  may  develop  haema- 
tomata  of  the  ears. 

Hallucinations  are  rare,  and  the  delusion  of  gran- 
deur is  less  insisted  upon ;  the  emotional  side  is  less 
stable,  and  the  memory  failing.  This  description  is 
only  a  typical  one,  for  each  case  has  some  peculiarity 
of  its  own.  I  have  known  patients  appear  for  a  day 
or  two  to  recover  their  mental  and  physical  powers  to 
a  surprising  extent. 

In  this  stage  there  may  be  a  tendency  to  subcuta- 
neous bruising,  and  to  the  formation  of  large  ab- 
scesses or  whitlows,  which  are  found  to  contain 
broken-down  blood  and  not  healthy  pus  ;  and  the 
inflammation  associated  with  the  condition  is  of  a  low 
type,  and  causes  little  pain.  Nevertheless,  blood- 
poisoning  and  sudden  death  may  occur. 

The  patient  may  remain  in  this  stage  for  any  time 
from  a  month  to  several  years.  He  may  become  fat 
and  flabby,  or  he  may  waste  rapidly  :  in  the  former 
case  fits  will  probably  return  ;  and  in  the  latter  some 
secondary  lung  affection  may  hasten  the  end. 

Loss  of  control  of  the  rectum  and  bladder  mark  tlie 
third  stage ;  at  first,  only  as  a  rare  accident,  or  only 
while  in  bed  j  but  later  all  control  is  lost ;  all  the 
bodily  and  mental  symptoms  become  accentuated. 
The  patient  also  now  loses  strength,  sits  about  unoc- 
cupied and  demented ;  being  either  iinable  to  walk  or 
unsteady  in  his  gait. 

He  may  get  wasting  and  contraction  of  the  legs, 
bed-sores  rapidly  forming.  These  latter,  however, 
often  show  a  strange  power  of  repair.  Swallowing 
becomes  difficult  and  dangerous,  the  tremulous  tongue 
can  hardly  be  protruded,  and  speech  is  thick  and  in- 
distinct. 


Chap.  XII.]      Third  Stage  of  Paralysis.  295 

Grinding  of  the  teeth  is  very  common. 

Loss  of  sensibility,  blindness,  and  deafness  may 
be  present ;  the  bones  may  become  brittle,  so  that  a 
very  slight  injury  may  break  a  rib  or  a  limb. 

The  fits  probably  become  more  frequent,  and  are 
associated  with  increase  of  temperature  and  profuse 
sweating,  which  may  be  local  or  general.  The  tem- 
perature may,  in  some  cases,  be  subnormal  apart  from 
the  fits. 

The  end  may  be  due  to  a  series  of  fits,  to  lung 
complications,  such  as  pneumonia,  to  simple  exhaus- 
tion due  to  bed-sores,  or  want  of  power  to  assimilate 
food ;  accidents,  such  as  choking  or  blood-poisoning, 
may  also  occur. 

Besides  the  above  there  are  cases  starting  with 
hypocliondriasis  passing  into  melancholia  with  re- 
fusal of  food  and  general  obstinacy,  diagnosis  being 
doubtful  for  some  time,  as  the  patient  will  neither 
walk,  speak,  nor  write  ;  the  pupils  may  be  unequal, 
and  the  skin  greasy.  In  many  cases  a  fit  may  clear 
up  the  case,  and  when  it  has  passed  into  the  second 
stage  it  runs  the  usual  course.  I  have  known  several 
pass  from  a  rather  prolonged  first  melancholic  stage 
into  a  long  stage  of  happy,  fat  weak-mindedness,  to 
be  followed  by  fits,  loss  of  power,  and  death. 

In  cases  starting  from  simple  weakness  of  mind, 
the  symptoms  vary  a  great  deal  :  one  sufiering  chiefly 
from  loss  of  memory,  while  another  becomes  querulous 
or  nervous.  The  bodily  symptoms  resemble  those 
already  described,  and  the  cases  pass  through  similar 
stages. 

I  have  seen  good  examples  oi  general  paralysis  of 
the  '''' double  form^^  the  point  that  has  struck  me  in  all 
being  the  extreme  differences  seen  in  the  two  stages. 
So  much  has  this  been  the  case  that  in  each  I 
have  doubted  whether  my  diagnosis  had  been  formed 
correctly.     Thus,   a    patient    admitted    with    typical 


296        Insanity  and  Allied  Neuroses.  [Chap.  xti. 

symptoms  of  general  paralysis  passes  into  a  state  of 
simple  melancholia,  most  of  his  Other  bodily  and 
mental  symptoms  having  remitted  j  this  having  lasted 
for  some  time,  a  fresh  outbreak  of  violence  and  exal- 
tation again  confirms  one's  first  opinion,  and  this  may 
again  be  succeeded  by  melancholia ;  each  attack, 
however^  leaves  some  mental  scars  to  prove  its  real 
nature. 

Some  cases  terminate  early  from  complications, 
others  pass  rapidly  through  the  ordinary  stages,  and 
others  are  specially  severe. 

Rapidly  fatal  general  paralysis. — E.  G.,  married, 
set.  33,  grandfather  melancholy,  parents  healthy  ;  the 
supposed  cause  of  this  attack  was  anxiety  about 
money  matters.  There  is  a  history  of  a  previous 
attack  of  insanity,  seven  years  before,  from  which  the 
patient  completely  recovered.  This  attack  lasted  four- 
teen days,  and  began  with  hesitation  in  speech  with 
great  incoherence,  sleeplessness,  and  refusal  to  take 
food.  He  fancied  that  his  shop  assistants  were  being 
starved,  and  that  people  were  removing  his  goods 
without  payment.  On  examination  when  admitted 
he  was  found  to  be  weak,  nervous,  and  restlessly  ex- 
citable. Within  three  months  he  was  noticed  to  be 
very  feeble  on  his  legs,  and  it  was  difficult  to  under- 
stand him,  as  his  speech  was  so  thick ;  later,  he  had  a 
convulsive  fit,  from  which  he  recovered,  but  remained 
in  a  half-dazed  condition.  There  was  no  special  para- 
lysis ;  but  great  exaggeration  in  the  reflexes.  Four 
months  after  admission  he  was  found  one  morning 
in  an  unconscious  state,  head  turned  to  the  right, 
with  conjugate  deviation  of  eye-balls  also  to  the  right, 
and  pulse  170,  respirations  55,  temperature  105°, 
right  pupil  slightly  larger  than  left,  loss'  of  power 
of  rectum  and  bladder ;  the  breathing  assumed  the 
Cheyne-Stokes  character  ;  he  became  more  profoundly 
unconscious,  and  died.  Post-mortem  :  the  convolutions 


Chap.  XII.]     Acute  General  .Paralysis.  297 

of  right  side  of  hemisphere  gave  the  idea  of  being 
wasted  from  compression  due  to  a  large  false  mem- 
brane, the  result  of  pachymeningitis,  in  which  a  soft 
clot  had  formed ;  the  pia  mater  peeled  off  readily,  the 
brain  weighed  43^  oz.,  and  beyond  pleuritic  adhe- 
sions on  both  sides  of  the  chest,  there  was  nothing- 
noteworthy  found  in  the  body.  On  microscopic 
examination  there  was  found  great  excess  of  connec- 
tive tissue  in  both  brain  and  cord,  this  being  widely 
diffused,  and  having  a  semi-transparent  gelatinous 
aspect  unlike  that  found  in  more  chronic  cases.  In 
the  above  case  the  peculiarities  were  insane  inheri- 
tance and  a  previous  attack  of  insanity ;  but  the 
point  to  which  I  desire  to  draw  attention  in  quoting 
this  case  is  the  rapidity  with  which,  when  once  the 
disease  became  fairly  started,  it  ran  its  course.  The 
symptoms  were  rather  melancholic  than  maniacal ; 
but  I  have  seen  many  cases  in  which  all  the  ordi- 
nary symptoms  of  general  paralysis  have  been  present, 
and  in  which  the  patient  has  died  within  three 
months.  This,  in  my  experience,  is  more  common 
with  maniacal  cases  than  either  with  those  suffering 
from  melancholic  symptoms,  or  those  of  simple  weak- 
mindedness. 

Acute  general  'paralysis  of  the  insane.  Fatal  re- 
sult.— Louis  F.  Gr.,  married,  set.  50,  artist ;  no  history 
of  insanity  in  the  family,  no  previous  attack  of  in- 
sanity, although  he  had  suffered  from  pleurisy  with 
delirium  two  years  before  ;  said  to  have  been  steady 
in  his  habits,  cheerful,  and  intelligent.  Two  months 
before  admission  he  was  noticed  to  be  irritable, 
nervous,  and  depressed.  He  lost  power  to  do  really 
good  artistic  work,  and  forgot  to  complete  orders  he 
had  on  hand.  He  went  from  London  to  Paris,  and 
was  unconscious  of  the  difference  of  the  cities.  On 
his  return  to  England  his  bodily  health  was  seen  to 
be  failing ;   he  was  sleeping  badly  and  his  appetite 


298         Insanity  and  Allied  Neuroses.  [Chap.  xri. 

decreasing.  There  seemed  to  be  difficulty  in  swallow- 
ing ;  he  was  clean  in  his  habits,  and  had  no  extrava- 
gance in  his  ideas.  He  mistook  himself,  and  when 
he  saw  his  image  in  the  glass  wished  to  smash  it. 
He  was  suspicious,  violent,  and  obstinate  about  his 
food.  The  diagnosis  was  general  paralysis  in  an 
early  stage.  Within  a  fortnight  of  admission  he  was 
so  weak  as  to  be  obliged  to  be  kept  in  bed.  Bed-sores 
rapidly  developed,  and  he  died  within  six  weeks.  The 
above  example  is  a  fair  one  of  what  is  met  with 
every  year,  some  running  even  a  more  rapid  course, 
and  being  complicated  by  convulsive  fits.  In  this 
case  no  post-mortem  was  allowed  to  confirm  the 
diagnosis. 

Example  of  chronic  case  of  general  paralysis  with 
severe  convulsions  recurring  during  the  greater  part  of 
the  disease,  and  death  at  the  end  of  nine  years. — 
George  E.  S.,  married,  set.  43,  butler,  admitted  for  the 
first  time  into  Bethlem  in  1866;  no  insane  inheri- 
tance. This  was  the  second  attack  of  acute  mental 
disorder,  there  having  been  a  distinct  remission 
between  the  first  and  second.  On  admission  he  was 
talking  incoherently,  was  dangerous  to  others,  filthy 
in  his  habits,  and  childish  in  his  general  behaviour. 

Althou2:h  on  the  first  admission  there  was  some 
doubt  as  to  the  nature  of  the  disease  from  which  he 
was  suff'ering,  on  his  second  admission  the  loss  of 
muscular  co-ordination  was  very  distinct,  lips  tremu- 
lous, and  gait  unsteady.  Incidentally,  he  had  an 
attack  of  erysipelas,  which  in  no  way  affected  the 
course  of  the  disease.  Steadily  the  symptoms  of 
general  paralysis  progressed,  and  two  years  after  his 
second  admission  he  is  described  as  thin,  much 
paralysed  generally,  speech  not  to  be  understood, 
some  contraction  of  right  arm  and  leg,  and  reflex 
action  exaggerated.  He  suffered  at  irregular  intervals 
from  fits.     During  the  next  three  years  fits  became 


Chap.  XII.]    Case  of  General  Paralysis.  299 

rather  fewer  in  number,  but  were  extremely  severe, 
lasting  sometimes  two  or  three  days.  He  became 
helpless  and  bed-ridden,  gradually  lost  sensibility, 
and,  his  breathing  becoming  implicated,  he  died,  after 
nine  years  of  disease.  Post-mortem  :  brain  found 
much  wasted,  dura  mater  adherent  throughout,  arach- 
noid with  many  milky  spots,  great  excess  of  sub- 
arachnoid fluid,  pia  mater  separable  from  cortex, 
several  convolutions  markedly  wasted,  especially  the 
left  ascending  parietal  and  frontal,  considerable 
wasting  in  the  right  side  posterior  to  the  fissure  of 
Rolando,  vessels  at  base  atheromatous,  cord  wasted, 
other  viscera  natural.  In  this  case  there  were 
symptoms  of  general  paralysis  occurring  nine  years 
before  the  death  of  the  patient ;  there  was  a  distinct 
interval  of  partial  health,  during  which  he  was  able 
to  live  at  home.  With  the  readmission,  there  ceased 
to  be  any  doubt  as  to  the  nature  of  the  disease, 
which  was  marked  by  progressive  dementia,  numerous 
epileptiform  fits,  and  ultimately  death.  Post-mortem  : 
a  wasted  brain,  with  special  wasting  along  the  motor 
area,  corresponding  with  the  right-sided  palsy. 

ExaTnple  of  ordinary  case  of  general  paralysis  in 
a  man. — Clarence  E.,  married,  set.  37,  wine  mer- 
chant, admitted  November,  1872;  no  insane  relations, 
not  very  sober  habits.  This  was  his  first  attack  of 
insanity,  and  anxiety  was  supposed  to  have  been 
the  cause ;  but  it  seems  that  he  had  been  unstable 
and  restless  all  his  adult  life,  having  been  first  a 
medical  student,  then  a  surveyor,  later  connected 
with  some  irregular  troops  in  New  Zealand,  and, 
last  of  all,  wine  merchant.  There  was  said  to  have 
been  an  injury  to  the  head,  but  intemperance,  at  ail 
events  for  a  time,  was  undoubted.  He  had  a  fit  of 
some  kind  in  New  Zealand,  and  this,  probably,  was 
the  starting-point  of  the  disease.  On  admission  he 
was  a  typical  example  of  mania  with  exaltation.      He 


300         Insanity  and  Allied  Neuroses.  [Chap.  xir. 

said  he  was  the  eldest  son  of  God,  that  he  was 
formerly  a  great  duke,  had  unbounded  wealth,  and  he 
was  liberal  and  benevolent  in  the  extreme.  He  told 
me,  with  regret,  that  the  patients  denied  that  he 
was  either  king  or  archbishop,  and  even  denied  his 
divinity ;  that  he  slept  from  twenty  to  sixty  hours  a 
night.  Occasionally  he  would  say  that  he  had  lost 
all  his  delusions,  but  it  only  required  a  minute's 
conversation  to  get  evidence  of  their  persistence.  In 
his  case  was  well  shown  the  inability  to  appreciate 
facts,  so  common  in  these  cases;  for  although  he 
would  boast  of  being  able  to  make  enormous  breaks 
at  billiards,  he  was  not  in  the  slightest  degree  dis- 
concerted by  being  beaten  by  a  tyro.  He  lost  strength 
and  flesh  rather  rapidly  during  the  first  few  months 
after  his  admission,  there  being  great  increase  of 
tremulousness  of  his  facial  and  lingual  muscles.  He 
walked  restlessly  and  quickly  about  the  grounds  for 
hours  together,  and  when  not  walking  was  writing 
endless  letters  and  dispatches  to  great  people.  His 
memory  next  became  markedly  affected,  and  his  sense 
of  colour  seemed  changed,  so  that  when  he  took  to 
painting  he  produced  the  most  astonishing  efiects. 
Six  months  after  admission  his  speech,  for  a  few 
days,  became  greatly  affected,  and  at  the  same  time 
there  was  loss  of  power  in  his  extremities,  but  there 
were  no  distinct  convulsions.  He  recovered  from  this, 
and  ate  and  slept  well,  becoming  contented  and  less 
boastful.     He  complained  of  spermatorrhoea. 

In  the  autumn  of  1873  he  had  a  slight  attack  of 
pneumonia,  from  which  he  recovered.  During  the 
year  1874  he  was  in  much  better  health,  and  even 
worked  in  the  gardens.  His  hand-writing,  however, 
became  characteristically  shaky,  and  early  in  1875 
his  aspect  became  dull  and  expressionless.  He  was 
unsteady  in  his  gait,  and  on  several  occasions  fell, 
bruising    himself.       His    muscles   were    fairly   well 


Chap.  XII.]    Case  of  General  Paralysis.  301 

developed,  his  memory  was  progressively  failing,  he 
was  easily  moved  to  tears ;  the  average  bodily 
temperature  was  98*4°  in  the  morning  and  100°  at 
night ;  loss  of  control  over  bladder  and  rectum 
appeared,  with  great  loss  of  sensibility.  In  May, 
1875,  there  was  evidence  of  a  convulsive  fit  during 
the  night;  but  he  recovered  from  this,  and  for 
another  month  gained  flesh.  In  1876  the  patient 
was  fat,  flabby,  and  demented.  He  was  unable  to 
stand,  and  the  reflexes  were  so  exaggerated  that  on 
several  occasions  he  was  nearly  jerked  from  his  chair 
by  them.  His  appetite  was  good,  his  lower  limbs 
somewhat  contracted,  the  right  pupil  larger ;  he 
laughed  senselessly  if  spoken  to,  and  resisted  any 
interference.  He  was  threatened  with  bed-sores, 
which  were  prevented  by  keeping  him  sitting  in 
suitable  chairs,  and  not  allowing  him  to  lie  in  bed  by 
day.  In  November,  1876,  he  had  a  severe  convulsive 
seizure,  affecting  the  right  side,  and  was  unconscious, 
but  restless.  He  recovered  from  this  fit,  but  was,  in 
every  way,  weaker,  his  lower  limbs  becoming  more 
contracted ;  he  ground  his  teeth  constantly,  making  a 
most  terrible  noise.  During  the  year  1877,  as  long 
as  he  lived,  he  never  regained  consciousness ;  he 
swallowed  automatically  when  food  was  put  into  his 
mouth,  but  never  articulated.  On  examination,  optic 
discs  were  found  pale  and  atrophied,  but  he  was  able 
to  see  to  a  certain  extent,  and  also  to  hear.  For 
months  he  remained  in  bed,  his  limbs  becoming  drawn 
up.  In  August  of  the  same  year  he  had  another  fit, 
the  fit  having  been  preceded  by  a  condition  of  ex- 
treme irritability  as  far  as  reflexes  were  concerned. 
The  head  was  drawn  to  the  right  side,  the  right 
pupil  larger;  there  were  clonic  spasms  of  lower  jaw 
and  occipital  and  frontalis  muscles.  He  recovered 
from  this  fit,  and  lived  on  till  March,  1878,  when  he 
died,  worn  out.     Post-mortem  :  the  body  was  greatly 


302  Insanity  and  Allied  Neuroses.  [Chap.  xii. 

emaciated,  with  rigid  flection  of  both  hips  and  knees  ; 
dura  inater  adherent,  arachnoid  thick  and  very 
opaque ;  great  excess  of  fluid,  so  that  the  brain  was 
softened  and  watery ;  cord  and  brain  both  much 
wasted ;  brain  weighed  38  oz.  ;  much  atheroma  of 
the  vessels  at  the  base  of  the  skull ;  signs  of  old 
inflammation  of  both  lungs  ;  wasting  of  kidneys,  and 
liver  nutmeggy.  This  case  will  be  seen  to  exhibit  all 
the  chief  characteristics  of  the  disease  we  are  con- 
sidering, but  was  unusually  long  in  its  course. 

Example  of  ordinary  case  of  general  paralysis  in 
a  woman. — Mary  A.,  married,  set.  36,  formerly  an 
actress,  no  insane  relations ;  present  attack,  the  first, 
supposed  cause,  great  anxiety  and  money  troubles 
of  her  husband.  The  first  symptoms  showed  them- 
selves nine  months  before  admission  in  March, 
1882.  She  became  excited  and  incoherent  for  twenty- 
four  hours,  and  from  that  time  there  was  marked  evi- 
dence of  mental  weakness.  This  progressed  till  it  was 
found  necessary  to  send  her  to  Bethlem.  On  admis- 
sion she  is  described  as  having  a  vacant  expression, 
but  that  she  was  always  wanting  to  be  dressed  elabo- 
rately, thinking  herself  to  be  a  great  personage.  When 
spoken  to  she  invariably  replied  by  saying  "jolly." 
She  walked  awkwardly,  her  speech  was  hesitating,  and 
her  comprehension  dull ;  her  expression  was  vacant ; 
her  appetite  was  good  j  there  was  loss  of  power  over 
bladder  and  rectum ;  within  one  month  of  admission 
she  became  noisy,  violent,  destructive,  refused  to  take 
food,  and  had  to  be  fed  with  the  stomach  pump.  An 
erythematous  rash,  followed  by  large  bullae,  appeared 
on  the  legs ;  the  temperature  was  subnormal.  She 
steadily  lost  strength  and  died.  Post-mortem  showed 
some  adhesions  of  dura  mater  of  the  skull,  arachnoid 
slightly  milky,  excess  of  subarachnoid  fluid ;  brain 
weighed  33  oz.;  marked  flattening  of  first  and  second 
frontal  convolutions,  and  over  the  whole  of  the  left 


Chap. XII.]  Paralysis  with  Exaltation.  303 

vertex ;  membranes,  when  separated,  left  roughened 
surface ;  arteries  not  atheromatous,  excess  of  fluid  in 
both  lateral  ventricles  ;  cord  wasted,  but  firm  ;  lungs 
both  congested,  with  adhesions  of  both  pleurae ;  kidneys 
small,  somewhat  granular;  small  fibroid  tumour  on  wall 
of  the  uterus. 

General  paTalysis  in  a  woman  ;  exaltation. — This 
is  interesting,  from  the  fact  that  it  occurred  in  a 
childless  woman  who  had  indulged  in  sexual  ex- 
cess, and  had  also  suffered  from  a  previous  attack  of 
insanity ;  and  to  the  fact  that  there  was  great  ex- 
aggeration of  ideas.  Charlotte  H.,  married,  set.  42,  no 
insane  relations;  had  a  first  attack  of  insanity  in  1872, 
when  she  accused  her  servant  of  drunkenness  and 
theft,  refused  to  pay  tolls  or  cab  fares,  and  squan- 
dered her  money  in  useless  ways,  pawning  her  jewel- 
lery to  obtain  money.  She  believed  herself  to  be 
pregnant ;  she  always  impressed  upon  us  the  fact  that 
she  was  going  to  be  delivered  of  triplets.  After  nine 
months'  treatment  she  was  discharged  to  go  home  to 
her  husband,  it  being  noted  that  she  had  settled  down 
into  chronic  weak-mindedness  of  general  paralysis,  but 
that  she  was  able  to  do  her  household  work.  She  re- 
mained at  home  till  January,  1875,  when  she  was 
readmitted  with  the  history  that,  three  months  before 
there  had  been  a  marked  exaggeration  of  her  symp- 
toms, her  memory  becoming  worse,  and  her  extrava- 
gance reappearing.  Her  memory  was  extremely 
defective,  both  for  recent  and  past  events,  so  that  she 
would  get  up  in  the  night,  with  the  idea  that  it  was 
morning,  to  prepare  her  husband's  breakfast.  She  was 
destructive,  tearing  up  her  clothes  ;  was  markedly 
tremulous  in  her  speech  ;  her  walk  was  unstable  ;  she 
was  unable  to  thread  a  needle  or  to  direct  any  precise 
movement.  The  right  pupil  was  the  smaller ;  eccen- 
tric, and  reacting  but  slightly.  Up  to  a  period  of 
three  months  before  her   readmission  she  had  been 


304         Insanity  and  Allied  Neuroses.  [Chap.  xii. 

excessively  amorous,  but  of  late  all  desire  ceased.  Tlie 
appetite  was  good,  and  she  slept  well.  From  the  time 
of  her  admission  to  the  time  of  her  death,  in  February, 
1876,  she  steadily  lost  ground,  bodily  and  mentally, 
dying  in  the  end  with  bed-sores  and  pneumonia,  the 
bodily  temperature  being  105^.  Post-mortem  :  dura 
mater  adherent,  arachnoid  free,  with  large  excess  of 
fluid ;  convolutions  much  wasted,  especially  on  left  side 
posteriorly,  and  about  fissure  of  Rolando  a  few  adhe- 
sions were  scattered  \  brain  was  tough  on  section ;  no 
excess  of  fluid  in  ventricles  ;  cord  wasted;  lungs  small, 
fibroid ;  kidneys  wasted,  with  adherent  capsules. 

General  'paralysis  with  a  2^eriocl  of  complete  re- 
'mission  ;  death  frora  hcemorrhage  into  spine. — In  the 
next  case,  an  attack  of  maniacal  excitement  caused 
the  admission  of  the  patient  into  Bethlem  two 
years  before  he  was  finally  admitted,  sufiering  from 
rather  advanced  general  paralysis,  from  which  he  died. 
Henry  J.  C,  single,  age  29,  has  one  sister  insane. 
Supposed  cause  of  present  attack  unknown ;  has  been 
a  commercial  traveller,  has  drank  a  good  deal,  and 
worked  very  hard.  His  first  symptoms  appeared  in 
August,  1873,  when  he  began  to  mope,  and  felt  un- 
able to  do  his  work.  He  ate  well,  but  slept  badly. 
After  the  period  of  depression  he  became  emotional 
and  excitable,  irritable  and  threatening.  He  also  be- 
came extravagant  and  generous ;  his  sleep  became 
profound ;  he  is  said  to  have  indulged  sexually  to  a 
great  extent ;  he  believed  himself  to  be  Christ.  On 
admission  he  was  very  maniacal,  dirty,  destructive,  and 
dangerous.  Bromide  of  potassium  and  cannabis  in- 
dica  were  given  with  little  eff'ect.  Morphia  also 
failed  to  keep  him  quiet.  An  abscess  formed  in  one 
leg,  from  which  grumons  unhealthy-looking  pus  was 
discharged,  and  it  was  with  difliculty  this  was  healed. 
Various  narcotics  and  sedatives  were  tried,  but  seemed 
to  have  little  or  no  effect  till  the  period  of  excitement 


Chap.  XII.]     Paralysis  with  Remission.  305 

passed  off  of  its  own  accord,  after  a  severe  attack  of 
purging  and  vomiting.  In  July,  1874,  he  was  reported 
as  convalescing.  In  September,  1874,  he  was  sent  on 
leave;  the  leave  was  extended  till  November,  when 
he  was  discharged ;  but  I  had  my  doubts  about  his 
recovery  being  complete,  as  he  could  not  recognise 
the  fact  that  he  had  been  excessively  violent  and 
dangerous.  He  was  readmitted  in  September,  1876, 
with  a  history  that  he  had  been  energetically  at 
work  for  a  year,  but  that  suddenly  he  had  become  ex- 
travagant, restless,  and  possessed  by  ideas  of  grandeur. 
On  admission  it  was  noticed  that  his  speech  was  greatly 
affected,  and  there  was  no  longer  any  doubt  as  to  the 
nature  of  his  disorder.  He  talked  freely  of  his  mil- 
lions, was  grand,  benevolent,  and  demonstrative,  and 
with  strongly  marked  erotic  tendencies.  A  t  the  begin 
ning  of  the  year  1877  he  lost  strength  and  flesh,  but  no 
physical  disease  could  be  detected.  Early  in  February 
of  the  same  year  he  wet  his  bed,  and  had  an  epileptic 
fit,  marked  by  half-opened  eyelids,  twitchiug  of  the 
eyelids  and  lip  muscles,  inversion  of  right  thumb, 
clonic  convulsion  of  hands  and  feet,  pupils  minute, 
right  the  larger,  temperature  98^.  In  the  evening  of 
the  same  day  the  fits  returned,  affecting  both  extre- 
mities, breathing  rapid,  skin  sweating,  temperature 
108'5°.  The  patient  then  died.  Post-mortem  :  brain 
was  found  to  be  of  full  size,  49-|  oz.,  with  no  special 
changes  beyond  excess  of  subarachnoid  fluid  ;  vessels 
at  the  base  atheromatous  ;  other  viscera  fairly  healthy 
with  exception  of  the  cord.  On  opening  the  spinal 
column  blood  of  a  dark  colour  escaped  from  the 
meninges.  On  tracing  this  upward  it  was  found  con- 
nected with  a  large  clot  surrounding  the  cervical 
region,  so  that  the  high  temperature  and  the  sudden 
termination  of  the  case  depended  upon  a  rupture  of 
an  atheromatous  artery  into  the  dura  mater  of  cord. 
Case  of  a  young  siiiyle  yirL — The  following  is  a 
TJ— 14 


300      Insanity  and  Allied  Neuroses.  [Chap.  xii. 

young  case,  in  some  respects  similar  to  the  last,  being 
single,  and  belonging  to  a  nervous  family,  and  being 
much  below  the  average  age.  E.  W.,  single,  set.  24,  an 
actress,  mother  given  to  drink,  and  other  relations 
exhibited  in  minor  ways  neurotic  tendencies.  This 
Avas  the  first  attack,  supposed  to  be  due  to  love  dis- 
appointment, the  truth  being  she  had  been  seduced 
and  abandoned.  The  first  symptoms  commenced  seven 
months  before  admission ;  change  of  temper  was  noticed, 
she  became  tremulous  and  jerky  in  movement,  and 
fancied  that  her  sister  treated  her  badly ;  she  was 
sleepless.  On  admission  she  was  restless  and  excited  ; 
she  said  she  had  seen  Christ  appear  to  her,  and  that 
he  had  given  her  a  new  skin.  She  spent  her  money 
recklessly,  and  she  claimed  high  connections.  The 
pupils  were  unequal,  the  left  being  the  larger  of  the 
two,  tongue  tremulous,  speech  hesitating,  very  emo- 
tional, and  with  varying  forms  of  exaltation,  so  that 
at  one  time  she  would  claim  twenty  husbands,  and  at 
another  would  say  she  possessed  boundless  wealth, 
especially  in  jewels  and  dress.  Her  bodily  health 
improved,  and  for  a  time  she  was  amiable  and  quiet, 
but  the  bodily  weakness  and  tremor  were  marked. 
The  temperature  during  this  time  varied  from  98"6°  to 
99*6°,  and  I  may  say  that  the  night  temperature  was 
generally  maintained  during  January,  1881,  at  100'2°. 
It  was  seen  that  her  highest  acquirements  became 
most  affected,  so  that,  though  she  believed  she  could 
still  dance  and  recite,  her  attempts  were  feeble  in  the 
extreme. 

During  February,  1881,  she  is  reported  to  have 
been  at  times  depressed,  and  complained  of  head- 
ache. She  pulled  out  her  hair  and  rubbed  holes  in 
her  forehead ;  the  tremor  of  hands  was  more  marked, 
patella  reflex  much  increased  ;  the  urine  neither  con- 
tained albumen  nor  sugar.  During  the  autumn  of  the 
same  year  she  had  improved  sufficiently  to  be  allowed 


Chap.  XII.]     Paralysis  with  Remission.  307 

to  go  to  the  theatre  with  a  sister ;  she  recognised 
several  people  whom  she  met  there,  and  spoke 
connectedly  about  the  past.  In  November  her  eyes 
were  carefully  examined  and  reported  to  be  normal, 
with  the  exception  of  haziness  of  the  lenses.  During 
the  first  few  months  of  1882  she  remained  in  much 
the  same  condition,  although  her  mind  seemed  to  be 
slowly  getting  w^eaker.  In  May,  1882,  the  catamenia 
reappeared  for  the  first  time  for  two  years  without  the 
slightest  mental  change.  During  the  rest  of  the  year 
she  lost  in  weight  and  became  quite  unable  to  stand, 
attempts  made  by  herself  resulting  in  falls  and  bruises. 
In  the  summer  of  1883  she  began  to  grind  her  teeth 
constantly,  and  gradually  loosened  nearly  the  whole 
set.  Further  physical  weakness  developed,  and  by 
August  she  was  bed-ridden,  unable  to  swallow  solid 
food,  legs  contracted,  with  slight  twitchings  of  muscles. 
There  were  no  marked  convulsive  fits,  but  during  the 
course  of  the  disease  there  had  been  several  attacks  of 
loss  of  consciousness  representing  the  same  condition. 
She  sank  slowly  and  died.  Post-mortem  :  the  brain 
weighed  36|  oz.  ;  great  excess  of  subarachnoid  fluid 
and  of  fluid  in  the  ventricles  ;  much  wasting  generally 
of  the  convolutions  ;  brain  substance  soft,  and  almost 
universal  adhesions  of  membranes  to  cortex;  both 
kidneys  in  a  condition  of  extreme  cystic  degeneration, 
with  very  little  secreting  structure  left ;  the  rest  of  the 
viscera  were  sufficiently  healthy. 

In  this  case  a  single  woman  of  twenty-four  years 
of  age  developed  general  paralysis,  which  was  some- 
what long  in  its  course,  but  presented  the  various 
mental  and  bodily  symptoms  met  with  in  the  disease  ; 
and  although  sexual  excess  may  at  some  time  have 
been  indulged  in,  it  certainly  had  not  been  for  some 
time  before  admission,  and  the  lapse  from  virtue  had 
been  of  short  duration.  One  other  point  was  the 
recurrence  of   menstruation  after  an   absence  of  two 


3o8       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

years.  I  have  met  with  two  or  three  female  cases 
of  general  paralysis  in  which  the  menstruation  has 
been  maintained  throughout ;  but  in  this  case  I  was 
surprised  to  find  a  re-establishment  without  any 
special  physical  change  or  mental  improvement. 

Case  of  general  'paralysis  in  a  young  single  woman., 
with  acute  course. — This  case  is  that  of  a  single  woman, 
set.  27,  machinist,  maternal  uncle  insane,  sister  died 
of  phthisis;  first  attack  of  insanity,  supposed  cause 
being  the  removal  of  a  tumour  under  chloroform 
seven  or  eight  weeks  before  admission.  Several 
slight  epileptiform  fits  came  on,  and  were  followed  by 
great  hesitation  in  speech,  loss  of  memory,  senseless 
laughter,  and  loss  of  power  of  lower  extremities.  On 
admission,  in  1883,  she  was  reported  to  be  suffering  from 
an  ichthyotic  condition  of  skin,  her  tongue  and  lips 
were  tremulous,  marked  hesitation  in  speech,  the  re- 
flexes were  normal.  She  had  hallucinations  of  hearing, 
and  was  emotional.  Although  there  was  no  marked 
exaltation,  yet  she  would  always  say,  however  feeble 
she  might  be  in  gait,  that  she  was  "  all  right."  Later, 
she  was  constantly  yawning,  the  reflexes  became 
exaggerated,  the  right  pupil  the  larger  ;  she  became 
restless,  dirty,  and  destructive,  so  that  she  had  to  be 
sent  into  another  ward.  By  the  end  of  January,  1884, 
she  was  bed-ridden,  and  rapidly  sank,  after  diarrhoea 
came  on.  Thus  her  case  was  acute  and  typical, 
although  occurring  in  a  single  young  woman. 

General  paralysis  in  a  woman,  following  worry. 
— M.  M.,  single,  set.  53,  schoolmistress,  admitted 
July,  1879,  no  insane  relations;  first  attack  of  insanity, 
said  to  be  due  to  over- work  and  anxiety ;  and  it  is 
certain  that  she  had  had  a  very  great  deal  of  worry 
and  pecuniary  trouble  for  a  year  or  more  before  she 
broke  down.  She  was  said  to  have  had  convulsions 
before  the  change  in  her  disjiosition  took  place,  there 
being  doubt  as  to  whether  they  were  epileptic.     On 


Chap.  XII.]   Paralysis  following  Worry.  309 

admission  she  had  many  delusions ;  she  thought  she 
was  being  poisoned,  and  that  she  and  those  about  her 
were  dead ;  she  was  obstinate  about  her  food,  and  was 
negligent  of  personal  cleanliness ;  she  had  halluci- 
nations of  sight  and  hearing  by  day  and  night ;  she 
feared  debt,  and  said  she  would  sooner  die  than  owe. 
Within  one  week  of  her  admission  she  was  served 
with  a  writ,  and  this  caused  a  great  deal  of  mental 
disturbance  ;  she  remained  excited  for  some  days,  and 
had  to  be  put  in  a  padded  room.  In  August  she  is 
reported  to  have  been  feeble  in  memory,  the  halluci- 
nations of  hearing  being  very  marked,  the  patient 
alleging  that  she  had  heard  conversations  between  the 
doctors  and  her  enemies.  At  the  end  of  August  she 
had  a  fit,  in  which  both  sides  were  convulsed,  but  there 
was  no  coma  nor  paralysis  ;  she  remained  for  a  time 
dazed,  but  on  the  fourth  day  became  maniacal  and 
violent,  and  continued  so  nearly  a  week.  After  the 
excitement  there  were  signs  of  physical  weakness,  and 
her  mind  and  memory  were  very  feeble,  so  that  she 
had  to  remain  in  bed.  In  the  middle  of  October  she 
had  another  fit,  being  excited  after  it,  the  excitement 
being  followed  by  right  hemiplegia,  speech  and  memory 
being  very  defective.  In  December  and  January  she 
had  other  fits  at  irregular  intervals,  the  peculiarity  of 
these  fits  being,  that  after  a  short,  sharp  set  of  con- 
vulsions the  patient  was  quiet  for  an  hour  or  two, 
then  became  maniacal ;  during  this  period  she  showed 
few  signs  of  paralysis  of  the  right  side,  although  her 
speech  was  still  thick.  After  a  few  days  of  excite- 
ment she  became  quiet  and  remained  in  her  bed, 
suffering  from  right  hemiplegia.  There  was  no 
material  change  till  the  28th  of  March,  when  she  was 
more  sensible  than  usual,  recognised  the  doctor,  and 
said  it  was  "  blessed  Easter- tide."  After  dinner  she  was 
seized  with  convulsions  of  the  left  arm  and  leg,  head 
drawn  to  left  shoulder ;  the  fits  were  clonic,  lasting 


3 TO      Insanity  and  Allied  Neuroses.  [Cimp.  xii. 

from  a  few  seconds  to  several  minutes.  The  eye-balJs 
turned  first  to  the  right  and  then  to  the  left ;  no 
increase  of  temperature  at  first,  although  the  next 
day  the  left  half  of  the  body  was  two  degrees  in 
excess  of  the  right.  Post-mortem  :  adhesions  of  mem- 
branes, especially  in  first  and  second  frontals,  ascend- 
ing frontal,  and  parietal,  left  side ;  in  right,  adhesion 
first  frontal  and  ascending  frontal ;  brain  46  oz. ;  heart 
\?>\  oz.  ;  kidneys  small,  wasted. 

General  imrahjsis  in  a  woman.  Pacliymenin- 
gitis. — A.  B.,  married,  set.  fifty  ;  one  sister  died  of 
puerperal  insanity,  another  of  delirium  tremens.  This 
patient  had  had  no  previous  attack  of  insanity, 
and  the  present  cause  is  supposed  to  have  been 
anxiety  about  her  husband's  business  matters,  two 
years  previously.  This  illness  began  with  sleepless- 
ness and  depression  six  months  before  admission ; 
she  then  became  weak-minded  and  forgetful,  at  times 
talked  incessantly,  at  other  times  was  restless  and 
irritable,  talking  in  the  wildest  way  of  her  being 
connected  with  the  Koyal  Family.  On  admission, 
July  31,  1883,  she  refused  food  and  had  to  be  fed 
with  a  stomach  pump  ;  she  constantly  pulled  ofi"  her 
clothes ;  her  speech  was  thick,  tongue  and  lips  tremu- 
lous, right  pupil  the  larger,  patella  reflex  well  marked, 
considerable  exaltation  of  ideas,  especially  about 
money ;  she  became  very  feeble  on  her  legs,  her  arti- 
culation became  worse,  and  memory  for  present  things 
defective.  On  the  24th  of  October  of  the  same  year 
she  had  a  series  of  convulsive  fits,  from  which  she 
rallied  a  little  ;  but  her  breathing  becoming  implicated, 
she  sank  and  died  on  the  3rd  of  November.  In  this 
case,  post  mortem,  was  found  great  wasting  of  some 
convolutions,  especially  about  the  junction  of  parietal 
with  occipital  regions  on  both  sides ;  there  was  also 
pachymeningitis  on  the  left  side,  with  general  wasting 
of  both  frontal  regions.     The  rest  of  the  body    was 


Chap.  XII.]  Pachymeningitis.  311 

not  examined.  In  this  case,  thongli  tlie  woman's  -age 
was  onlj'"  fifty,  her  appearance  was  that  of  at  least 
sixty  ;  the  symptoms  were  very  characteristic,  there 
being  progressive  weak-mindedness,  exaltation  of  ideas, 
restless  destructiveness,  associated  with  lingual  and 
labial  tremor,  loss  of  power,  convulsions,  and  death. 

General  paralysis  in  an  old  man.  Pacliynienin- 
gitis. — S.  B.,  set.  sixty-one,  but  with  an  aspect  of  a 
man  of  seventy,  married,  an  artist,  no  insane  rela- 
tions ;  no  previous  attack  of  insanity,  the  present 
one  dating  back  six  months,  supposed  to  be  due 
to  pecuniary  losses,  showing  itself  with  forgetfulness 
of  small  things  ;  he  became  incoherent  and  childish, 
losing  himself  in  his  own  house,  mistaking  his  rela- 
tions, and  neglecting  the  decencies  of  society,  rest- 
less, fidgety,  rubbing  his  head  with  his  hands.  On 
admission,  November  22nd,  1883,  there  was  great 
tremulousness  of  lips  and  tongue,  with  hesitation  of 
speech.  After  admission  he  became  more  restless  and 
interfering,  and  at  the  same  time  he  lost  mental 
power.  A  month  after  admission  he  had  a  series  of 
convulsive  seizures,  from  which  he  again  recovered, 
but  he  was  left  distinctly  weaker  in  mind  after  the 
convulsions.  At  the  end  of  January  he  had  a  further 
series  of  fits,  from  which  again  he  recovered.  Mental 
and  physical  weakness  increased,  and  he  died,  pachy- 
meningitis being  found  post  mortem. 

The  above  case  is  a  good  example  of  the  difficulty 
which  may  arise  in  distinguishing  between  senile 
weak-mindedness  and  genera,l  paralysis  of  the  insane, 
and  the  diagnosis  can  scarcely  be  considered  complete 
till  the  post-mortem  examination.  My  opinion  that 
it  was  general  paralysis  was  founded  upon  the  pro- 
gressive weak-mindedness,  restlessness,  tremulousness 
of  tongue  with  hesitation  of  speech,  together  with 
the  recurring  convulsive  seizures  which  left  no  per- 
manent paralysis. 


312      Insanity  and  Allied  Neuroses.  [Chap.  xii. 

Oeneral  paralysis  with  simple  prog^res- 
sive  dementia. — As  I  have  said,  the  natural  mental 
termination  of  general  paralysis  is  weak-mindedness, 
but  in  some  cases  this  is  developed  without  any  inter- 
mediate stages  of  excitement  or  depression.  This 
may  follow  in  cases  beginning  with  convulsions,  or  it 
may  occur  in  cases  such  as  that  about  to  be  described, 
without  any  definite  explanation.  The  weak-minded- 
ness may  show  itself  as  simple  loss  of  memory,  as 
loss  of  power  to  accommodate  one's  self  to  one's 
surroundings,  or  as  a  childish  emotionaj  condition, 
or  as  one  of  boyish  frolicksomeness,  or  as  cowardice. 

The  following  case  of  general  paralysis  with 
simple  progressive  dementia  is  a  fair  example.  E. 
M.,  married,  set.  46,  merchant;  no  insane  relations, 
mother  died  paralysed,  one  brother  died  of  apoplexy. 
This  was  the  first  attack,  the  cause  being  great 
money  losses  and  anxiety  about  his  family.  He 
had  always  been  temperate  and  hard-working.  He 
had,  as  his  first  sign  of  mental  degeneration,  a 
convulsive  seizure  two  and  half  years  before  he 
was  considered  insane.  His  present  illness  began 
with  incoherence  and  confusion  of  thought  and  speech  ; 
he  was  unable  to  enter  into  any  rational  conversation, 
and  had  a  vacant  expression  of  face.  On  admission, 
September,  1880,  he  was  stout  and  expressionless, 
with  feeble  power  of  reaction  and  negligent  of  his 
personal  appearance.  His  optic  discs  were  found  to 
be  in  a  state  of  grey  atrophy.  The  reflexes  were 
exaggerated,  and  nearly  all  the  muscles,  both  of  face 
and  limbs,  were  found  to  be  unduly  irritable  to  the 
electric  current.  Bodily  this  patient  improved,  so 
that  he  became  more  than  one  stone  heavier  in  seven 
months,  but  mentally  he  grew  weaker;  the  right  pupil 
was  larger  than  the  left,  and  reacted  to  accommoda- 
tion, but  not  to  light.  There  was  great  tremor  of 
facial  muscles  and  hesitation   in  speech.     This  patient 


Chap.  XII.]  Paralysis  with  Melancholia.  313 

exhibited  a  mental  peculiarity  which  is  not  uncom- 
monly seen  in  general  paralytics,  so  that  there  was 
a  temporary  and  limited  re-establishment  of  the 
intellect;  and  although  he  got  progressively  weaker 
in  mind,  he  occasionally  brightened  np  and  re- 
cognised his  friends  and  relations,  and  could  even 
understand  his  position  as  a  patient  in  an  asylum. 
Such  periods  of  remission  are  not  uncommonly  fol- 
lowed by  convulsions  or  exaggeration  of  mental  weak- 
ness. By  February,  1883,  the  patient  became  greatly 
emaciated,  and  there  was  contraction  of  his  neck  and 
lower  extremities.  He  spent  most  of  his  time  in  an 
unconscious  state.  At  the  end  of  February  he  had  a 
severe  series  of  epileptiform  fits,  and  died.  Post-mor- 
tem :  the  brain  weighed  44  oz. ;  great  excess  of  fluid 
in  membranes  and  in  ventricles ;  adhesions  of  mem- 
branes to  cortex ;  on  both  frontal  convolutions  and  on 
the  right  frontal  lobe  there  was  considerable  wasting ; 
the  arteries  at  base  atheromatous  ;  the  aorta  extremely 
atheromatous ;  both  kidneys  peeled  badly,  the  rest  of 
the  viscera  were  normal,  except  that  the  lungs  were 
oedematous. 

Oeneral  paralysis  witti  melaiicliolic 
syifiiptoms. — A  great  deal  has  recently  been  written, 
more  especially  by  Yoisin,  on  the  subject  of  general 
paralysis  with  hypochondriacal  and  melancholic  symp- 
toms, and  I  think  he  deserves  credit  for  pointing  out 
the  number  of  patients  who  die  from  this  variety  of 
the  disease,  and  who  have  never  shown  any  of  the  more 
usual  symptoms  accompanying  it.  I  find  that  the  gene- 
ral practitioner  looks  upon  exaltation  of  ideas  and  the 
inequality  of  pupils  as  the  two  pathognomonic  signs 
of  general  paralysis ;  but  asylum  physicians  must  all 
have  been  struck  with  the  cases  which  are  admitted 
into  an  asylum  obstinately  refusing  food,  losing  flesh, 
and  causing  anxiety  from  their  feebleness,  and  in 
the  end  dying.     Some  such  cases,  with  care  and  by 


314      Insanity  and  Allied  Neuroses.  [Chap.  xii. 

means  of  artificial  feeding,  rapidly  improve,  and  the 
physician  looks  for  recovery  ;  but,  instead  of  that,  the 
patient,  becoming  fat,  also  becomes  weak-minded.  It 
is  then,  perhaps,  noticed  that  there  is  inequality  of 
pupils,  tottering  gait,  and  marked  loss  of  expression. 
There  has  been  difficulty  from  the  very  onset  to 
get  the  patient  to  put  his  tongue  out  or  to  speak, 
hence  the  condition  of  tremor  has  not  been  noticed. 
In  such  an  instance,  if  fits  occur,  the  case  is  cleared  up ; 
but  if  not,  it  must  be  looked  upon  as  one  of  dementia 
consecutive  to  melancholia.  In  all  these  cases  deatli 
results,  and  both  doctor  and  friends  are  astonished  at 
the  fatal  result.  Some  cases  do  not  recover  at  all, 
but  pass  from  melancholy  to  extreme  physical  weak- 
ness, or  death,  the  whole  period  of  the  process  being 
but  a  few  months. 

In  looking  over  the  records  of  the  deaths  of 
patients  in  Bethlem,  I  meet  with  many  that,  I  am 
now  sure,  belonged  to  the  class  of  melancholia  with 
general  paralysis  which  were  not  then  recognised  as 
such,  although  I  used  to  point  out  that  a  certain 
number  of  melancholic  patients  always  died,  and 
without  w^hat  appeared  to  be  sufficient  pathological 
cause.  The  subjoined  case  is  a  typical  one  of  the 
kind.  John  C,  admitted  January,  1874,  married, 
set.  47,  merchant,  no  insane  relations ;  first  attack  of 
insanity,  which  had  lasted  six  weeks,  caused  by  loss 
of  money  and  anxiety,  and  began  with  the  loss  of 
identity.  He  refused  to  take  food  because  he  believed 
he  could  not  afford  it,  and  also  because  he  thought 
people  were  trying  to  poison  him.  After  admission 
he  was  reported  as  silent  and  obstinate,  refusing  his 
food,  negligent  of  his  person,  and  sleepless.  He  had 
to  be  fed  artificially.  There  was  a  history  of  a  con- 
vulsive seizure  during  the  early  part  of  his  illness. 
He  slowly  lost  strength,  but  remained  perverse  and 
melancholv.     I  was  unable  to  discover  anv  cause  for 


Chap.  XTI.]  jP^^yiZF^/5  WITH  TONGUE  TrEMOR.  315 

his  physical  deterioration,  and  for  the  difficulty  in 
breathing  which  came  on.  He  sank  and  died  in 
March  the  same  year.  Post-mortem :  brain  fifty 
ounces  ;  dura  mater  adherent ;  somewhat  thickened 
arachnoid  with  many  opaque  patches  ;  subarachnoid 
fluid  in  great  excess ;  considerable  wasting  of  con- 
volutions, the  right  frontal  lobes  being  most  reduced ; 
vessels  at  base  atheromatous ;  brain  matter  fairly 
firm ;  and  only  other  changes  found  in  the  lungs  were 
due  to  pneumonia.  Other  similar  cases  have  occurred 
in  which  convulsions  reappeared,  or  in  which  other 
bodily  symptoms  had  made  themselves  manifest. 

General  paralysis  \^itli  little  toitgue 
tremor. — In  the  opinion  of  one  or  two  of  the  oldest 
physicians  in  our  specialite,  tremulousness  of  tongue 
with  hesitation  in  speech  are  the  invariable  symptoms 
of  the  general  paralysis  ;  but  I  would  at  once  give  as 
my  opinion  that,  although  this  is  generally  true,  it  is 
but  an  example  of  the  more  general  principle  that  the 
most  highly  developed  faculties  suffer  soonest.  Speech, 
with  all  the  delicate  control  of  the  tongue,  is  one  of  the 
last  human  acquirements,  and  in  any  condition  of  pro- 
gressive mental  degeneration  will  suffer  as  a  rule ; 
but  there  will  be  exceptions,  which  at  present  are  not 
to  be  explained  ;  and  I  am  quite  used  to  meet  jDatients 
suffering  undoubtedly  from  general  paralysis,  yet  with 
little  or  no  tremor  or  hesitation.  The  following  is  a 
very  good  example. 

Thomas  A.,  married,  set.  43,  ironmonger,  paternal 
grandfather  and  maternal  cousin  insane,  phthisis  pre- 
sent on  the  paternal  side.  His  first  attack  of  insanity, 
which  had  lasted  three  months,  could  not  be  attributed 
to  any  definite  cause.  It  began  by  great  irritability 
and  extravagance,  with  sleeplessness,  and  ideas  that 
he  was  possessed  of  immense  wealth  and  power ; 
that  he  had  received  revelations  from  God,  and  that 
he  was  married  to  most  of  the  duchesses  in  England. 


3t6      Insanity  and  Allied  Neuroses.  [Chap.  xii. 

Both  pupils  were  contracted,  but  reacted  to  light  and 
accommodation  ;  tongue  clean,  moist,  and  very  slightly, 
if  at  all,  tremulous;  his  walk  was  ataxic;  the  reflexes 
normal ;  his  hand-writing  shaky  and.  abbreviated ;  but 
his  speech  as  clear  as  possible  ;  and  his  facial  muscles 
without  loss  of  expression.  This  case  has  now  been 
five  months  under  observation  ;  I  am  convinced  that 
the  patient  is  suffering  from  general  paralysis,  and 
yet  there  is  no  marked  change  in  expression  of  face, 
nor  is  there  hesitation  in  speech. 

ISpiual  g'eueral  paralysis.— There  is  a  group 
of  cases  in  which  either  the  paralytic  symptoms 
precede  the  mental  symptoms,  or  in  which  they  are 
very  much  more  pronounced.  In  cases  already  re- 
ported it  will  have  been  remarked  that  most  of 
those  which  terminated  fatally  exhibited  paralysis 
of  the  lower  extremities  more  or  less ;  and  I  be- 
lieve the  process  of  degeneration  is  one  affecting 
the  whole  nervous  tissues,  and,  therefore,  sure 
to  implicate  the  spinal  cord,  if  the  disease  lasts 
long  enough.  A  question,  which  at  present  I  am  not 
in  a  position  to  discuss,  has  been  referred  to  recently 
by  Dr.  Mickle,  for  since  Terrier  has  elaborated  his 
ideas  on  the  localisation  of  function  in  the  cortex  of 
the  brain,  observers  of  general  paralysis  of  the  insane 
have  sought  to  localise  degenerations,  representing  the 
special  lines  of  weakness  met  with  in  these  cases.  It 
would  be  of  some  importance  to  be  able  to  say  of  the 
patient  with  general  paralysis  associated  with  tabes, 
that  degeneration  would  be  found  in  such  and  such  a 
part  of  the  motor  area ;  or  that,  if  the  case  be  one  with 
changes  in  the  lateral  columns,  another  part  of  the 
cortex  would  be  affected.  That  this  will  be  demon- 
strated sooner  or  later  I  feel  sure.  The  following 
cases  are  examples,  jirst  of  general  paralysis  asso- 
ciated with  ataxic  symptoms ;  the  second,  of  those  in 
whom  the  symptoms  pointed  to  a  change  in  the  lateral 


Chap.  XII.]    Ataxy  PRECEDING  Paralysis.  317 

columns,  which  post-mortem  examination  confirmed. 
The  first  group  may  again  be  divided  into  those  in 
which  ataxy  preceded,  and  those  in  which  it  developed 
with  or  after  the  general  paralysis. 

The  following  case  is  an  example  of  ataxy  'pre- 
ceding general  paralysis^  which  exemplifies  very  well 
the  progressive  nature  of  the  degeneration  \  the 
patient  not  only  had  typical  ataxy,  but  became  both 
blind  and  deaf,  and  showed  symptoms  of  bulbar 
paralysis.  R.  M.,  married,  aet.  47,  merchant,  no 
insane  relations,  mother  died  asthmatic,  no  known 
cause  for  the  illness.  The  first  symptoms  showed 
themselves  at  the  end  of  1877,  when  he  refused  to  see 
people,  and  threatened  to  drown  himself.  He  had 
increasing  difificulty  in  expressing  his  ideas,  became 
altered  in  manner,  his  memory  failed,  and  even  then 
had  a  habit  of  letting  his  saliva  run  from  his  mouth. 
Before  admission  he  became  reckless  in  business,  and 
emotional,  especially  at  night,  when  he  would  bellow 
for  hours  together.  On  admission  he  thought  every 
one  was  against  him,  he  refused  food,  had  exaltation 
of  ideas,  thickness  of  speech,  and.  ataxic  walk, 
which  had  been  present  some  year  or  more;  there 
was  some  nystagmus.  Two  months  after  admission 
he  was  reported  to  be  more  shaky  on  his  legs,  and 
optic  discs  to  be  partly  atrophied;  later  he  had  a  slight 
attack  of  faintness  followed  by  slight  loss  of  power  in 
left  thigh;  patella  reflex  was  absent.  At  the  end  of 
1878  both  discs  were  described  as  markedly  atrophic, 
and  deafness  was  also  noted.  Although  feeble,  he 
was  restless,  constantly  trying  to  move  rapidly  about. 
In  •November  he  had  a  fit,  and  from  that  time  lost 
power  rapidly.  After  the  fit  he  was  reported  to  be 
unconscious,  the  tongue  dry  and  brown,  pulse  74, 
axillary  temperature  98°,  surface  temperature  of  fore- 
head, right  side,  93-8°,  left,  94-6°;  there  was  twitching 
of  the  right  side,  inability  to  swallow,  left  pupil  larger 


3i8      Insanity  and  Allied  Neuroses.  [Chap,  xii. 

both  pupils  being  insensible  to  light.  The  patient 
died,  the  brain  exhibiting  wasting  with  some  adhesions, 
the  cord  showing  evidences  of  changes  in  the  posterior 
columns. 

In  the  next  case  symptoms  of  rapid  general  para- 
lysis and  ataxy  have  developed  together.  Thomas 
J.  B.,  married,  set.  51,  clerk,  no  insane  relations ; 
first  attack  of  insanity,  supposed  to  depend  on  intem- 
perance, although  he  has  been  temperate  for  the  last 
two  years.  A  slight  attack  of  depression,  lasting  one 
week,  occurred  two  years  ago,  at  the  time  when  he 
became  teetotal.  He  has  had  two  severe  falls,  but 
there  are  no  signs  of  local  head  injury.  The  first 
symptoms  of  this  attack  occurred  three  weeks  before 
his  admission,  on  September  21st,  1883,  when  he 
became  strange  in  manner,  unable  to  attend  to  his 
business,  sleepless,  with  exaltation  of  ideas,  believing 
himself  to  be  a  very  great  man,  able  to  compose 
poetry,  and  paint  pictures  at  least  fit  for  the  Academy. 
He  said  his  father  was  the  son  of  a  nobleman. 
He  was  restless,  boastful,  and  encroaching,  con- 
stantly moving  rapidly  about,  and  willing  to  race  or 
fight  with  any  of  the  patients;  pupils  small,  but 
equal ;  memory  for  recent  events  bad  ;  walk  unsteady, 
legs  being  thrown  away  from  the  body  and  falling  on 
the  heels  ;  patella  reflexes  absent ;  says  he  does  not 
feel  the  ground ;  on  closing  his  eyes  he  reeled  and  fell 
at  once.  There  was  but  little  tremor  about  the  lips, 
and  slight  irregularity  or  hesitation  in  speech.  He 
continued  happy  and  contented  with  his  powers, 
making  many  pictures  and  filling  reams  of  paper.  On 
September  28th  it  was  reported  that  there  was  diver- 
gence of  eyes  and  consequent  diplopia,  on  account  of 
which  he  kept  right  eyelid  down.  There  was  marked 
cerebral  giddiness  when  left  eye  was  closed,  no  evi- 
dent changes  visible  in  his  discs.  Since  September 
both  bodily  and  mental  weakness  steadily  progressed, 


Chap.  XI  1.1   Lateral  Sclerosis  of  Cord.  319 

and  the  case  is  now  a  marked  one  of  general  paralysis 
in  an  advancing  stage,  witli  ataxic  symptoms.  So  far 
I  have  never  met  with  a  female  case  of  general  para- 
lysis in  which  ataxy  was  marked  ;  the  same  rule 
seeming  to  hold  with  this  as  with  ordinary  ataxy, 
that  women  rarely  if  ever  suffer. 

L<atera1  sclerosis  of  cord  livltb  g^eneral 
paralysis. — The  next  class  of  cases  is  one  in  which 
I  have  taken  very  special  interest,  the  symptoms  in 
many  particulars  grouping  themselves  regularly,  so 
that  I  am  hopeful  at  all  events  that  this  variety  of 
general  paralysis  will  prove  to  be  not  a  mere  formal 
division,  but  a  natural  class.  The  first  important 
peculiarities  which  I  have  encountered  are  that  it 
frequently  occurs  in  women  as  well  as  in  men ;  that 
it  occurs  in  the  single  as  well  as  in  the  married  ;  and 
in  patients  much  younger  than  the  average  age  for 
general  paralysis.  In  a  certain  number  of  the  cases  I 
have  met  there  has  been  an  undoubted  history  of 
syphilis.  On  the  bodily  side  the  walk  is  peculiar  and 
spasmodic,  giving  one  the  idea  that  no  sooner  has  the 
foot  touched  the  ground  than  a  reflex  is  immediately 
started,  causing  the  foot  to  jump  suddenly  up  ;  the  re- 
flexes are  exaggerated,  clonus  being  at  times  present ; 
optic  disc  changes  may  also  occur.  A'^ery  frequently 
capillary  stigmata  are  present  over  the  malar  bones, 
and  develop  for  a  time  as  the  disease  jDrogresses. 

Male  case  of  general  'paralysis.,  with  lateral  scle- 
rosis, and  fatal  termination.  —  Francis  R.,  single, 
pet.  30,  medical  student,  no  history  of  insanity  ;  first 
attack  of  six  months'  duration,  said  to  have  followed 
excesses,  and  a  former  attack  of  syphilis.  The 
first  symptoms  were  change  in  disposition,  oddness 
in  behaviour,  and  absence  of  mind.  He  had  always 
been  vain  about  his  appearance  and  his  powers, 
and  this  had  developed  into  extreme  exaltation,  so 
that   he    looked  upon    himself  as  a  perfect  paragon, 


320       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

notwithstanding  the  fact  that  he  had  failed  to  pass 
even  his  preliminary  examination.  On  admission, 
September,  1881,  he  was  a  man  of  medium  height, 
squarely  built,  fair  complexion,  with  bright  malar 
capillary  congestion.  His  walk,  although  constant, 
was  of  the  jerky  kind  I  have  described,  the  patella 
reflexes  exaggerated,  the  pupils  unequal,  the  right 
being  the  larger,  both  reacting  to  accommodation,  but 
slightly  only  to  light.  For  twelve  months  he  slowly 
developed  weak-mindedness,  great  hesitation  in 
speech,  the  facial  and  lingual  tremors  being  extreme, 
and  his  whole  appearance  being  one  of  great 
nervous  irritability,  the  very  approach  of  any  one 
causing  him  to  give  a  general  start.  He  lost  control 
over  his  bladder  and  rectum,  and  slowly  became 
indifferent  to  his  surroundings,  neither  reading  nor 
associating.  By  October,  1882,  he  was  quite  unable 
to  walk  alone,  and  could  not  articulate  a  single  word, 
was  very  wet  and  dirty,  and  the  lower  extremities 
were  becoming  contracted.  From  this  time  he  lost 
ground  steadily,  and  died  in  March,  1883.  Post- 
inortem  :  excess  of  subarachnoid  fluid,  with  opacities 
of  that  membrane  ;  the  membranes  peeled  readily,  but 
left  both  frontals  rough,  especially  the  left ;  ventricles 
large,  containing  excess  of  fluid ;  brain  weighed  forty- 
four  ounces  ;  cord  wasted,  with  very  well-marked  de- 
generation in  the  lateral  columns. 

Female  case^  vjith  lateral  sclerosis  of  general  para- 
lysis, and  fatal  terjnination. — Edith  C,  married, 
set.  35,  printer's  wife,  no  history  of  insanity  in  the 
family ;  first  attack  of  six  weeks'  duration.  This 
patient,  although  married,  had  no  children,  and  in 
this  particular  resembles  several  other  cases  I  have 
met  with,  in  whom  the  symptoms  of  general  para- 
lysis have  been  associated  with  childless  marriage. 
She  was  admitted  in  March,  1883,  the  first  symp- 
toms    having     been    false    accusations    against    her 


Chap.  XII.]  Lateral  Sclerosis.  321 

husband.  She  then  became  incoherent  and  restless, 
wandering  about  in  her  night-dress,  saying  her 
husband  wanted  to  poison  her.  She  was  excitable, 
and  had  exalted  ideas  about  riches  ;  thought  there 
was  some  chloroform  in  her  husband's  brain,  that  he 
was  mad,  and  that  she  was  a  duchess.  On  admis- 
sion she  had  hallucinations  of  taste  ;  the  pupils  were 
extremely  small  but  equal,  and  this  is  noteworthy.  In 
these  cases  the  pupils  are  frequently  pin-points,  and 
equal,  reacting  but  very  slightly.  She  slept  badly,  her 
walk  was  shaky  and  unsteady,  and  reflexes  were  greatly 
exaggerated.  The  ophthalmoscopic  examination  did 
not  show  any  changes.  After  admission  she  steadily 
got  more  feeble  in  gait,  more  tremulous  in  speech, 
with  difficulty  of  swallowing,  and  loss  of  power  over 
bladder  and  rectum.  In  May  of  the  same  year  she 
had  an  epileptiform  attack  with  general  convulsions, 
but  the  symptoms  were  most  marked  on  the  right 
side.  From  this  time  she  lost  power  and  sank. 
Post-mortem  :  great  general  wasting  of  convolutions, 
especially  of  the  ascending  frontal,  right  side ;  adhesions 
of  membranes  of  first  right  frontal ;  great  dilatation 
of  lateral  ventricles  ;  brain  weighed  forty -four  ounces  \ 
cord  wasted,  with  marked  changes  in  the  lateral 
columns ;  other  viscera  healthy,  except  atheromatous 
condition  of  arch  of  aorta.  This  last  case  is  one  of 
about  ten  that  I  have  now  met  with,  in  which  the 
ordinary  mental  symptoms  of  general  paralysis,  with 
exaggeration  of  reflexes  and  exaltation  of  ideas,  have 
occurred  in  married  women  of  middle  age ;  and  I  hope 
to  collect  my  observations  on  these  cases  in  a  future 
number  of  the  Guy's  Hospital  Heports. 

Cases  ipith  remissions. — In  many  cases  of  general 
paralysis,  which  have  begun  with  the  wildest  maniacal 
excitement,  this  passes  ofl",  to  be  replaced  by  a  period 
of  arrest  or  even  remission  of  the  symptoms ;  and  it  is 
important  to  remember  that  the  remission  may  appear 
v— 14 


322       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

to  be  so  complete  that  patients  are  discharged  recovered, 
only  to  be  readmitted  in  a  much  more  advanced  stage  of 
the  disease.  The  remissions  may  be  of  variable  length, 
rarely  lasting  more  than  twelve  months.  They  occur 
more  frequently  in  those  cases  in  which  the  symptoms 
have  been  acutely  maniacal ;  they  very  rarely  occur 
more  than  once  in  any  single  case.  I  can  only  re- 
member one  patient  in  whom  there  was  more  than  one 
distinct  remission.  These  remissions  are  rarely  com- 
plete, one  or  other  of  the  bodily  or  mental  symptoms  per- 
sisting ;  and  I  should  say  from  my  experience,  that 
the  tremor  of  lips  and  tongue,  if  once  established,  rarely, 
if  ever,  passes  ofif ;  pupil  irregularity  may  pass  off,  as 
well  as  changes  in  the  reflexes  or  exaltation  of  ideas. 
The  only  case  in  which  cure  of  general  paralysis  seemed 
to  me  to  have  occurred  was  that  of  McC;  but  I  regret 
to  say  that  recently  I  have  evidence  that  he  is  again 
suffering  from  some  obscure  nervous  disease,  there- 
fore I  can  scarcely  claim  him  as  an  undoubted  cure. 

The  following  is  his  case :  D.  McC,  married, 
set.  50,  railway  agent,  no  insane  inheritance ;  the 
first  attack  of  insanity  requiring  seclusion,  although 
he  had  been  peculiar  four  years  before ;  cause  said  to 
have  been  over-work  ;  was  sober  and  industrious,  all 
ideas  of  syphilis  being  repudiated.  The  first  symp- 
toms were  those  of  excitement,  with  incoherent 
rambling  conversation,  exaltation  of  ideas  both  as  to 
wealth  and  station;  was  benevolent  with  his  exaltation, 
offering  to  benefit  all  his  friends  with  thousands  of 
pounds.  He  believed  that  he  had  a  secret  which  was 
for  the  benefit  of  the  human  race.  On  admission, 
October,  1879,  he  talked  incessantly,  with  the  wildest 
exaltation ;  was  sleepless,  haggard,  worn,,  and  rest- 
less, being  unable  to  stand  still  for  a  minute.  He 
was  treated  with  hyoscyamine  for  a  time  without  any 
benefit.  He  was  incoherent,  and  his  left  pupil  was 
very  much  larger  than  his  right.    He  informed  me  that 


Chap.  XII.]     Paralysis  with  Remission.  323 

a  London  oculist  had  told  him  it  was  due  to  syphilis  : 
but  he  indignantly  denied  ever  having  that  disease. 
His  speech  was  hesitating,  and  he  got  worse,  although 
his  general  health  improved ;  he  took  several  hours  to 
finish  a  short  letter.  In  December  of  the  same  year  an 
inquisition  was  held,  at  which  well-known  physicians 
gave  evidence  to  the  effect  that  he  was  suffering  from 
general  paralysis,  and  not  likely  to  recover.  He  was 
wet  and  dirty  at  times,  and  his  memory  became 
progressively  weaker.  On  January  20,  1880,  a  car- 
buncle on  the  back  of  his  neck  began  to  form,  and. 
rapidly  spreading,  caused  an  enormous  swelling,  fol- 
lowed by  sloughing,  which  extended  from  the  nape  of 
the  neck  to  both  shoulder-blades.  No  sugar  in  the 
urine  was  discovered.  From  the  time  of  tlie  appearance 
of  this  carbuncle  his  mental  symptoms  improved,  and 
by  the  20th  of  March  he  was  much  improved  men- 
tally and  bodily.  He  was  sent  to  Witley,  and  after 
that  he  was  on  leave  till  the  end  of  May,  when  he  was 
discharged  well.  Some  months  later,  after  repeated 
applications,  a  supersedeas  was  granted  by  the  Court 
of  Chancery,  and  once  more  he  was  allowed  to  manage 
his  affairs,  and  till  recently  was  considered  by  his 
friends  of  sound  mind  and  body.  Since  then  I  have 
heard  that  he  is  under  treatment  with  anomalous 
paralytic  symptoms,  but  without  mental  disorder, 
the  opinion  of  his  physician  being  that  he  is  suffering 
from  some  syphilitic  nerve  lesion.  As  the  above 
case  has  for  four  years  been  at  large,  and  has  been 
able  to  establish  his  sanity,  after  at  least  five  experts 
of  distinction  had  considered  him  as  a  general  para- 
lytic, it  is  suflQciently  noteworthy. 

General  jyaralysis  with  remission.  —  Henry  W., 
married,  set.  37,  silver  chaser,  admitted  February 
9th,  1881,  no  insane  relations;  the  first  attack  due  to 
business  anxieties,  and  the  first  symptoms  showed 
themselves  two   months  before   admission,    when   he 


324       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

bought  a  plot  of  land  without  being  able  to  pay  for  it. 
He  talked  about  travelling,  and  taking  a  hundred  of 
his  friends  with  him  ;  he  was  going  to  build  a  large 
house,  become  a  member  of  Parliament,  and  was  full 
of  extravagance  and  joyousness.  On  admission  he 
was  a  tall,  spare  man,  sleeping,  eating,  and  digesting 
well,  pupils  contracted.  These  conditions  were  asso- 
ciated with  tremor  and  hesitation  of  speech,  and  change 
in  hand-writing,  while  restlessness  was  one  of  the  most 
marked  symptoms.  This  attack  passed  away,  and  in 
April  of  the  same  year  he  was  sent  down  to  our  con- 
valescent home,  and  then  for  a  month's  leave  of  absence 
to  his  own  home.  At  the  end  of  his  leave  he  was  so 
much  recovered  that  he  was  discharged,  his  friends 
being  warned  that  it  was  only  a  remission,  and  that 
the  symptoms  would  probably  soon  start  afresh,  and 
then  would  be  fatal. 

On  the  18th  of  October,  the  same  year,  he  was 
brought  back  to  Bethlem,  his  friends  saying  he  had 
slept  well  till  ten  days  before  admission,  when  once 
more  he  became  extravagant,  and  possessed  of  false 
ideas  of  the  value  of  money.  He  collected  rubbish, 
thinking  it  was  gold,  talked  with  much  hesitation 
of  speech  about  millions,  and  of  the  hippopotami 
he  was  going  to  stock  his  farm  with.  It  was  now 
noticed  that  his  expression  was  dull,  that  there  was 
great  tremor  of  lips  and  tongue,  the  pupils  small  and 
equal,  skin  greasy,  speech  clipped  and  hesitating, 
memory  bad ;  he  was  very  restless  and  mischievous, 
tearing  up  books  or  clothes.  At  this  time  there  was 
no  change  in  his  optic  discs.  In  bodily  health  he 
improved,  getting  quite  fat  and  healthy-looking,  in 
which  condition,  with  progressive  loss  of  memory,  he 
remained  till  August,  1882,  when  he  had  a  fit,  the 
temperature  not  being  raised,  and  there  being  but  slight 
convulsions  associated  with  the  unconsciousness. 
From  time  to  time  he  had  other  nts^  which  were  always 


Chap.  XII.]    Double  Form  of  Paralysis.  325 

of  the  following  nature :  without  warning  of  any 
kind  he  fell  forward  on  to  the  floor,  and  with  slight 
twitching  of  all  his  limbs  lay  there  unconscious  for 
from  ten  minutes  to  an  hour,  passing  his  urine  and 
faeces  under  him.  His  recovery  was  like  that  of 
one  waking  from  sleep;  and  although  each  fit  left  him 
mentally  weaker,  the  change  was  only  small.  In 
February,  1883,  his  vision  was  noticed  to  be  weak,  the 
pupils  still  contracted,  but  not  circular  ;  left  optic 
disc  pale,  sharply  defined ;  right  optic  disc  very 
white,  edges  very  sharply  defined ;  knee-jerk  well 
marked.  He  always  replied  that  he  was  "very  well," 
if  spoken  too.  The  fits  recurred  ;  but  it  was  strange 
that  even  during  the  last  month  of  his  life,  on  several 
occasions  he  so  far  collected  himself  as  to  be  able  to 
speak  not  only  consistently,  but  accurately,  about 
things  which  had  happened  in  the  hospital  two  years 
before ;  this  is  only  another  example  of  the  extraor- 
dinary way  in  which  general  paralytics  will  temporarily 
recover  from  almost  any  symptoms.  Towards  the  end 
of  December  of  the  same  year  he  became  unable  to 
swallow,  lost  flesh  rapidly,  and  died.  Post-mortem  : 
brain  weighed  49  oz.,  there  being  excess  of  subarach- 
noid fluid  ;  but  a  remarkable  absence  of  adhesions 
between  brain  and  membranes ;  the  brain  itself  was 
remarkably  firm,  the  cord  firm,  with  a  considerable 
amount  of  fluid  within  the  membranes ;  both  lungs 
congested  posteriorly ;  there  was  atheroma  also  in 
large  amount  in  the  aorta.  This  case  illustrates  what 
has  been  said  about  remissions  ;  and  although  yearly  I 
am  obliged  to  discharge  patients  whom  their  friends 
consider  perfectly  recovered  from  attacks  of  insanity 
which  I  attribute  to  general  paralysis,  yet  these  cures 
prove  invariably  but  remissions. 

General  paralysis  of  the  double  form. 
— Cases  of  this  variety  were  described  at  the  In- 
ternational   Medical    Congress    of    1881,    by   Dr.    de 


326       Insanity  and  Allied  Neuroses,  [Chap.  xii. 

Lemaestre.  Hitherto  tliej  have  not  been  sufficiently 
recognised  in  England.  It  is,  of  course,  open  to 
objectors  to  say  that  they  are  only  varieties  of  general 
paralysis  with  remissions,  the  period  of  remission  being 
marked  by  typical  reaction  from  the  state  of  exaltation. 

Herbert  F.,  single,  set.  42,  accountant,  no  in- 
sane relations ;  first  attack  of  insanity,  no  cause 
known.  Admitted,  April,  1883,  the  symptoms  having 
existed  about  six  weeks  ;  they  began  with  nervousness 
and  twitching,  followed  by  depression  and  threats  of 
suicide.  This  soon  was  replaced  by  great  exaltation  of 
ideas,  and  extravagance.  He  believed  himself  rich 
and  powerful,  and  offered  marriage  to  several  ladies. 
Tongue  tremulous ;  pupils  equal ;  hallucinations  of 
hearing  ;  memory  weak ;  sleeps  well ;  excessive  patella- 
reflexes  ;  writing  shaky.  Five  weeks  after  admission 
he  had  swelling  of  both  legs,  and  some  unhealthy- 
looking  pustules  formed.  In  June  he  was  variable, 
weaker  in  mind,  and  emotional.  In  September  he 
became  melancholic  and  said  he  had  offended  God; 
but  again  he  became  emotional,  violent,  and  passionate. 
In  February,  1884,  he  was  quiet,  and  had  not  any 
of  the  old  exaltation,  his  appearance  being  that  of  one 
suffering  from  melancholy  with  stupor.  His  circula- 
tion was  very  feeble,  his  hands  being  livid  and  con- 
gested. There  was  little  loss  of  expression;  the 
tremor  of  tongue  and  hesitation  of  speech  were  less, 
yet  he  was  wet  and  dirty.  If  he  had  been  seen 
for  the  first  time  in  February,  he  would  hardly  have 
been  recognised  as  a  general  paralytic  ;  and  this  is  one 
of  the  chief  characteristics  of  this  variety,  that  it  may 
impress  the  observer  first  as  unmistakable  general 
paralysis,  the  change  in  the  character  of  the  disease 
throws  doubts  upon  the  diagnosis,  and  another  change 
may  confirm  the  first  opinion. 

Such  cases  may  begin  with  melancholia  and  pass 
into  exaltation  ;  or  may  begin  with  mania  and   pass 


Chap.  XII.]  The  Optic  Discs.  327 

into   melancholy.      Each   change,   however,  shows  in- 
crease of  mental  weakness. 

I  wish  I  could  give  as  distinct  groujis  of  patho- 
logical changes  as  I  have  given  of  clinical  symptoms, 
but  at  present  I  am  not  quite  prepared  to  accept  all 
Dr.  Mickle's  divisions  as  final. 

Special  consideration  of  symptoms.— 
It  will  now  be  necessary  rapidly  to  run  over  the 
symptoms  which  occur  in  general  paralysis,  and  in 
doing  this  I  shall  first  discuss  the  bodily  and  then 
the  mental  symptoms.  The  pupils  are  said  to  be 
generally  unequal,  I  shall  give  as  my  experience  that 
in  one  group,  those  associated  with  change  in  the 
lateral  columns  of  the  chord,  the  pupils  are  frequently 
reduced  to  pin-points,  and  in  an  asylum,  if  I  meet  with 
a  case  with  such  smallness  of  pupils,  I  at  once  expect 
a  further  development  of  the  symptoms  of  general 
paralysis.  Inequality  of  pupils  is  common  but  not 
constant,  varying  not  only  in  the  different  stages  of 
the  disease  itself,  but  from  day  to  day ;  the  pupils  are 
at  one  time  eccentric  and  at  another  irregular  in  out- 
line. In  the  later  stages  of  the  disease  they  are  often 
dilated.  In  tabetic  cases  the  reaction  to  light  is  de- 
fective, but  to  accommodation  it  may  exist.  I  have  no 
knowledge  of  any  relation  between  dilatation  of  the 
pupil  of  one  side  being  associated  with  any  special 
symptoms,  and  I  should  at  once  deny  the  proposition 
that  with  dilatation  of  either  pupil  there  is  constantly 
exaltation  of  ideas.  Fallacies  must  be  guarded  against, 
patients  without  general  paralysis  must  be  recognised 
as  sometimes  having  inequality  of  vision  in  their  eyes 
and  inequality  of  pupils.  I  have  been  misled  for  a 
time  in  patients  who  had  syphilitic  iritis,  and  once 
by  a  patient  with  a  false  eye. 

Strabismus  and  ptosis  are  rare  in  general  para- 
lysis, and  permanent  mydriasis  is  also  rare  unless 
associated  with  syphilis.     The  condition  of  the  optic 


»3 


28       Insanity  and  Allied  Neuroses.  [Chap.  xii. 


discs  has  been  discussed  for  years  past,  and  my  expe- 
rience at  Bethlem  is  that  in  the  early  stages  of 
general  paralysis,  whatever  the  variety,  there  is 
certainly  no  constant  change  in  the  discs.  There  is  no 
hypersemia,  no  grey  degeneration,  nor  any  alteration 
either  in  vessels  or  nervous  tissues.  Later,  and  more 
generally,  changes  begin  to  show  themselves  in  a 
certain  number  of  cases  towards  the  end  of  the 
second  stcge,  and  although  it  is  uncommon  to  find 
any  really  distinct  optic  neuritis,  changes  associated 
with  dimness  of  outline  of  the  disc  and  with  fulness 
of  vessels  become  manifest.  Vision  may  or  may  not 
be  affected  ;  as  a  rule  it  is  either  very  slightly  changed, 
or  the  patient  is  so  weak  in  mind  that  it  is  not  ap- 
preciated. In  about  equal  numbers  those  patients 
suffering  with  tabetic  symptoms  and  those  with  lateral 
sclerotic  symptoms  are  affected  by  changes  in  the  optic 
disc,  and  in  several  cases  sight  was  completely  lost.  A 
full  account  of  those  changes  which  may  occur  in 
the  optic  discs  will  be  found  in  the  Ophthalmological 
Heports  of  1883,  vol.  iii.,  the  reports  being  by  Dr. 
Edmunds,  of  St.  Thomas's,  and  Dr.  Lawford,  clinical 
assistant  at  Bethlem. 

In  my  experience,  hearing  is  not  so  commonly 
affected,  and  I  have  only  met  with  two  or  three  cases 
in  which  in  the  last  stage  of  general  paralysis  of  the 
insane  hearing  was  lost  almost  entirely. 

As  to  taste  and  smelly  though  I  have  perseveringly 
tried  Yoisin's  experiment  as  to  the  loss  of  ability  to 
detect  the  smell  of  pepper  in  early  general  paralysis,  so 
far  I  have  met  with  very  few  cases  in  whom  this  defect 
was  present ;  I  have  met  recently  with  a  case  of  rapid 
general  paralysis  with  general  anaesthesia  and  progres- 
sive dementia  in  which  pepper  was  not  recognised;  but 
all  the  other  symptoms  were  sufficiently  well  marked, 
and  this  symptom  was  of  no  practical  use  at  all.  Taste 
and  smell,  then,  are  in  my  experience  rarely  affected. 


Chap.  XII.]    Tremor  of  Lips  and  Tongue.  329 

Next  in  importance  to  the  pupils,  and  according  to 
some  even  of  the  first  importance,  is  the  condition  of 
tremulousness  of  Hjjs  and  tongue.  Ah^eady  I  have 
said,  that  of  all  muscular  co-ordinations  in  the  body 
those  of  the  lingual  muscles  are  most  highly  organised, 
and  in  degeneration  suffer  most  and  earliest.  The 
nature  of  the  tremor  has  been  variously  described  by 
one  as  fibrillar,  and  by  another  as  general.  I  should 
say  that  in  the  earliest  stages  in  which  it  is  present  it 
is  marked  by  a  slight  irregular  want  of  control,  the 
patient  projecting  it  by  little  jerks  at  a  time,  as  if  un- 
certain how  much  force  was  being  used,  and  to  what 
extent  the  tongue  was  protruded.  The  tongue  itself 
often  has  lost  its  expression,  and  is  irregular  in  out- 
line ;  as  disease  advances  it  becomes  still  larger  and 
more  flabby,  and  if  protruded  at  all,  will  be  found  to 
rest  on  the  lower  lip  ;  the  tremor  is  less  in  the  morn- 
ing than  during  the  latter  part  of  the  day ;  it  may  be 
all  but  absent  after  periods  of  complete  rest,  but  after 
talking,  and  more  especially  after  eating,  it  is  well 
marked.  I  think  it  is  more  manifest,  as  is  also  the 
tremulousness  in  the  lips  in  general  paralysis,  with 
changes  in  the  lateral  columns.  With  the  tremor  of 
tongue  and  of  lips  has  to  be  connected  the  clipping  of 
words ;  this  varies  considerably,  some  patients  scan- 
ning almost  like  those  with  disseminated  sclerosis, 
others  halting  in  speech  or  dropping  the  terminations 
of  the  words.  It  is  interesting  to  remember  that  the 
change  is  very  similar  both  in  writing  and  in  speech, 
so  that  just  as  there  is  a  dropping  of  letters  there  is  a 
clipping  of  words. 

Besides  speech  alteration  there  are  other  changes 
in  which  the  tongue  is  affected.  In  the  most 
advanced  cases  great  difficulty  of  swallowing  arises, 
and  this  is  one  of  the  causes  of  fatal  accidents  to 
these  patients.  I  have  seen  several  cases  who  have 
introduced  into  their  mouths  large  masses  of  food  or 


33°       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

even  big  pieces  of  bone,  which  they  have  managed  to 
get  lodged  at  the  back  of  the  throat,  with  imminent 
risk  of  suffocation.  In  the  early  part  of  the  second 
stage  it  is  not  uncommon  to  get  peculiar  movements  of 
the  jaws,  as  if  the  patient  were  swallowing  his  saliva. 
There  may  be  a  noisy  movement  of  the  lips,  or,  what  is 
most  common,  grinding  of  the  teeth,  which  when  once 
established  rarely  is  lost ;  so  that  patients  becoming 
rapidly  demented  will  grind  their  teeth  for  hours 
together,  making  the  most  objectionable  noise,  and 
by  this  means  eventually  teeth  may  be  broken  or 
forced  from  their  sockets.  The  food  is  swallowed  by 
these  patients  unmasticated,  and  the  appetite,  which  in 
the  earliest  stage  of  general  paralysis  may  be  capricious, 
becomes  insatiable;  the  bowels,  at  first  constipated, 
become  regular  during  the  greater  part  of  the  disorder, 
but  in  the  later  stages  diarrhoea  is  not  uncommon,  masses 
of  undigested  food  being  passed.  I  have  been  unable  to 
discover  any  special  elements  in  the  food,  Miich  seemed 
to  pass  altogether  unaffected  by  the  digestive  processes. 
The  skin  in  general  paralysis  is  noteworthy.  In 
acute  cases  the  face  is  pallid,  often  waxy ;  later, 
when  expression  is  being  destroyed,  the  skin  becomes 
thicker  and  greasy,  the  greasiness  appearing  most 
about  the  forehead  and  the  nose.  This  is  often  so 
marked  that  on  passing  a  fore-finger  over  the  side 
of  the  nose  and  closing  the  thumb  on  it  the  sensation 
as  of  powdered  French  chalk  is  given.  I  know  of 
no  special  skin  disease  associated  with  general  para- 
lysis, but  in  later  stages  I  have  met  with  irregular 
bullae  appearing  at  different  parts  of  the  body.  In  the 
lateral  sclerotic  variety  I  have  commonly  met  with  a 
great  deal  of  capillary  congestion  over  the  malar  pro- 
minences. The  import  of  this  is  doubtful;  it  may  merely 
be  a  coincidence,  or  it  may  be  that  general  paralysis 
and  this  condition  both  occur  in  certain  temperaments  ; 
or  it  may  be  that   certain   vaso-motor  paralyses   lead 


Chap. XII.]      The  Muscles  in  Paralysis.  331 

botli  to  general  paralysis  and  capillary  congestion  ;  but 
still,  in  this  case  I  do  not  understand  why  the  conges- 
tion should  be  so  localised.  There  may  be  some  con- 
nection between  these  congestions  and  oth-hsematomata 
and  pachymeningitis.  I  have  rarely  met  with  hyper- 
sesthesia  in  general  paralysis,  but  anaesthesia  is  com- 
mon. It  may  occur  in  localised  patches  in  the  earlier 
stages  of  the  disease,  and  may  vary  from  day  to  day  in 
the  area  over  which  it  extends.  It  may  pass  off  alto- 
gether for  months,  again  to  reappear  in  the  later 
stages  of  the  disease.  In  some  cases  it  is  extreme,  so 
that  I  have  known  a  patient  fall  asleep  with  his  hand 
in  front  of  the  fire  till  it  was  completely  roasted ;  and 
in  another  case  a  patient  who,  having  a  contraction 
due  to  a  burn  affecting  his  left  arm,  got  a  piece  of 
pumice-stone  and  during  one  night  rubbed  an  inch  or 
more  of  the  web  into  a  hole.  This  anaesthesia,  I  believe, 
may  alter  the  reaction  of  the  reflexes ;  thus,  on  one 
occasion,  a  patient  who  for  a  long  period  had  been  my 
best  example  of  exaggerated  patella  reflex,  when  tried 
was  found  to  have  lost  this  symptom,  and  on  further 
investigation  I  found  he  was  completely  ansesthetic 
in  his  lower  extremities.  Danger  arises  to  such  cases, 
as  they  are  liable  to  bruise  themselves  unconsciously, 
and  cases  have  been  scalded  to  death  by  getting  into 
a  bath  of  hot  water. 

The  muscles  in  general  paralysis  may  remain  well 
nourished  and  active  for  a  long  period.  It  has  been 
said  that  there  is  no  alteration  in  the  electrical  relation- 
ship of  these  muscles,  and  I  must  own  that  the  expe- 
rience gained  in  Bethlem  by  the  use  of  the  currents, 
the  examination  being  made  by  skilled  electricians, 
has  led  to  no  results.  Stray  muscles  here  and  there 
were  found  to  be  losing  power  without  any  definite 
reason  ;  my  own  feeling  is  that  in  most  cases  there  is 
undue  excitability  in  nearly  all  muscles  during  the  first 
stage ;  and  that  this  excitability  is  much  more  marked 


332       Insanity^  and  Allied  Neuroses.  [Chap.  xii. 

in  those  cases  which  afterwards  exhibit  fully  developed 
symptoms  of  lateral  sclerosis,  in  whom,  towards  the 
end  of  the  disease,  extreme  contraction  of  the  lower 
extremities  takes  place.  For  a  very  considerable  time, 
even  up  to  death,  the  other  cases  maintained  rounded 
limbs,  the  muscles  being  of  the  ordinary  size ;  although 
with  them,  as  with  the  tongue,  I  should  say  there  is  a 
want  of  expression. 

In  the  same  relationship  we  must  look  upon  the 
hand-writing^  to  which  symptom  so  much  importance 
has  been  attached.  As  general  paralysis  advances, 
the  patient  becomes  less  able  to  write,  but  there  is 
nothing  absolutely  characteristic  in  the  hand- writing 
itself.  Tremor  may  occur  with  age,  with  alcoholism, 
with  paralysis  agitans,  with  melancholia,  and  mania  ; 
and  I  have  specimens  of  hand-writing  from  all  the 
above  which  are  indistinguishable.  It  is  interesting 
to  compare  the  hand- writing  of  the  general  paralytic  in 
health  and  in  disease,  there  being  the  same  general 
character  in  the  writing,  although  there  is  the  tremor 
visible  in  both  upstroke  and  downstroke  as  the  dis- 
ease progresses;  but  the  shakiness  alone  is  of  no  im- 
portance, unless  the  terminal  letters  are  noted  to  be 
occasionally  omitted.  In  a  few  cases  I  have  seen  a 
marked  improvement  in  legibility  in  hand-writing  in 
early  general  paralysis,  the  fact  being  that  patients 
finding  themselves  unable  to  write  quickly  have,  on 
this  account,  taken  more  pains  with  what  they  did. 
As  the  disease  advances  the  patient  can  no  longer 
write  with  a  pen,  but  may  be  able  to  control  a  pencil; 
and  with  this  the  words  become  more  and  more  abbre- 
viated, so  that  when  he  is  bed-ridden  his  speech  is 
becoming  indistinguishable,  and  he  is  no  longer  able 
to  write  at  all. 

The  hones  of  the  general  paralytic  sometimes  be- 
come remarkably  brittle  ;  and  when  I  hear  of  many 
fractures    in    a    single    patient   in    an    asylum,   I  am 


Chap.  XII.]      HmMATOMATA    IN    THE    EaRS.  333 

inclined  rather  to  blame  the  ribs  than  the  attendants. 
I  have  known  a  general  paralytic  get  a  fractured 
radius  from  a  light  blow  with  a  hair-brush.  Such 
fractures  not  unfrequently  unite  naturally,  and  this 
is  one  of  the  peculiarities  of  many  general  paralytics, 
that,  although  they  may  receive  fractures,  develop 
bed-sores  or  abscesses,  these  rapidly  heal. 

Besides  the  above  changes  there  is  a  tendency  to 
low  forms  of  inflammation  in  the  subcutaneous  areolar 
tissue,  so  that  in  the  first  place  we  may  meet  with 
sluggish  forms  of  whitlow  or  "  mad-fingers  j"  or  else 
light  bruises  may  produce  enormous  abscesses,  which 
contain  pus  mixed  with  broken-down  blood.  In  one 
case  a  patient,  simply  by  slipping  out  of  his  bed, 
bruised  the  outer  side  of  his  thigh,  producing  no 
abrasion  of  skin,  but  within  two  days  there  was  an 
enormous  bruise  with  oedema  and  tense  swellinfif,  re- 
sembling  a  bad  case  of  phlegmonous  erysipelas,  which 
led  to  a  large  abscess  j  he  recovered,  however, 
without  any  bad  symptoms,  and  without  sloughing 
of  skin.  On  the  other  hand,  a  patient  died  in 
Bethlem,  and  the  friends  were  ill-satisfied  in  conse- 
quence of  the  bruised  condition  of  his  body ;  a  slight 
blow  on  the  face  having  caused  an  enormous  sub- 
cutaneous haemorrhage,  and  a  fall  on  his  back  from  a 
bed  having  produced  a  symmetrical  haemorrhage  into 
both  loins  of  an  extraordinary  amount.  ISTo  signs  of 
the  injury  were  visible  for  two  days,  when  it  was 
noticed  that  both  buttocks  were  becoming  black  ;  the 
patient  sank  suddenly  of  acute  septicaemia,  and  post 
mortem  a  felt-like  clot  of  disorganised  blood,  with 
unhealthy  looking  pus,  was  found .  between  the  sub- 
cutaneous areolar  tissue  and  the  muscles.  I  believe 
that  the  hcematomata  which  occur  from  time  to  time 
in  the  ears  of  general  paralytics  have  a  similar  origin. 
These  hsematomata  are,  in  my  opinion,  more  common 
in  general  paralytics  than  in  other  cases.    I  have  seen 


334       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

tliem  more  than  once  in  cases  of  chronic  insanity ; 
once  in  insanity  with  phthisis  and  refusal  of  food  ;  in 
chronic  mania  with  restless  destructiveness  ;  and  in 
secondary  dementia,  with  obstinacy  about  food.  The 
left  ear  is  more  commonly  affected  than  the  right, 
and  this  certainly  lends  weight  to  the  idea  that  trau- 
matism, in  the  shape  of  the  right  hand  of  the  at- 
tendant, has  something  to  do  with  the  causation.  I 
have  only  seen  one  case  in  which  a  patient  was  dis- 
charged well,  having  had  marked  hsematomata.  My 
own  feeling  is  that  the  causation  of  these  swellings 
is  altered  condition  of  blood,  and  altered  condition 
of  smaller  vessels,  associated  with  violence  of  some 
kind.  Similar  hsemorrhages  certainly  occur  in  other 
parts  of  the  body  when  violence  has  been  exercised. 

Convulsions  have  been  treated  in  two  ways  by 
those  who  have  written  on  general  paralysis  of  the 
insane,  some  treating  them  as  essential  symptoms  of 
the  disease,  others  considering  them  to  be  complica- 
tions. Without  pretending  to  explain  their  causation 
fully,  I  look  upon  them  as  a  common,  although  not 
essential  symptom,  and  yet  not  as  a  mere  complica- 
tion. The  convulsions  may  be  the  very  first  noticed 
symptoms ;  the  first  convulsion  may  be  extremely 
severe,  or  it  may  be  of  a  very  slight  nature.  In  one 
or  two  cases  I  have  the  history  that  patients  have 
had  slight  attacks  of  what  looked  like  the  petit  Trial 
of  epilepsy  for  some  time  before  general  paralysis 
became  fully  recognised.  In  one  case  slight  faintness 
followed  by  aphasia  occurred  some  years  before  the 
patient  had  to  be  removed  from  home.  The  convul- 
sions may  be  at  one  time  extremely  severe,  and  at 
another  but  very  slight  in  character,  sometimes  being 
mistaken  for  a  mere  faint ;  or  they  not  uncom- 
monly resemble  a  bilious  attack.  It  is  more 
common  to  meet  with  fits  in  patients  who  have 
become  fat,   and  who  have  become  quieter,   than    in 


Chap.  XII.]  Convulsions.  335 

those  who  have  passed  through  the  first  stage 
altogether;  and  in  such  cases  the  fits  will  mark 
a  passage  from  the  first  to  the  second  stage. 
The  fi-ts  may  be  general,  the  patient  falling  down, 
with  or  without  a  cry,  completely  unconscious,  and  con- 
vulsed all  over  his  body  ;  the  convulsions  may  be  more 
marked  on  one  side  than  on  the  other,  and  they  may 
be  noticed  to  start  always  from  one  spot ;  they  may 
pass  off  in  the  course  of  a  few  seconds,  or  they  may 
recur  on  the  slighest  external  irritation  for  days  toge- 
ther. Some  fits  have  been  called  apoplectic  from 
their  extreme  severity,  and  from  their  more  frequently 
affecting  one  side  of  the  body  only.  Many  patients 
have  convulsions  on  the  one  side  followed  by  temporary 
hemiplegia,  but  I  have  not  been  able  to  trace  any 
relationship  between  the  part  convulsed  and  the  in- 
equality of  the  pupils  :  although  in  some  cases  I  have 
found  that  the  side  which  was  convulsed,  and  which 
afterwards  became  paralysed,  at  the  onset  of  the  dis- 
ease, was  in  a  more  excitable  condition  electrically 
than  the  opposite.  The  results  of  convulsions  in 
general  paralysis  are  remarkable.  They  pass  off  more 
rapidly  than  if  organic  lesion  were  present,  as  in 
apoplexy  ;  and  less  readily  than  in  ordinary  epilepsy: 
pointing,  it  seems  to  me,  in  many  cases  to  an  inter- 
mediate pathological  condition,  to  a  condition  in 
which  the  discharge  arises  in  consequence  of  not 
merely  functional  instability,  but  to  alteration  in  the 
structure  of  the  cortex.  Besides  the  physical  changes 
which  follow  convulsions,  the  mental  deterioration 
which  succeeds  them  is  remarkable,  many  patients 
becoming  rapidly  weaker  and  more  childish  after  each 
fit.  In  one  case  I  have  seen  a  remission  ushered  in 
by  a  fit.  At  the  time  of  the  convulsions  various 
treatments  have  been  suggested  :  nitrate  of  amyl  has 
been  given,  but  I  have  failed  to  find  any  good  result 
from  its  administration. 


336       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

From  convulsions  one  naturally  passes  to  a  con- 
sideration of  the  temperature  in  general  paralysis. 
The  fits  are  almost  invariably  associated  with  altera- 
tions in  temperature,  some  cases  having  a  marked 
increase  shortly  before  convulsions.  I  have  myself 
been  fortunate  enough,  on  one  or  two  occasions,  to  have 
taken  the  temperature  of  a  patient  who  within  the 
hour  had  convulsions ;  and  in  such  cases  it  was 
usually  two  or  three  degrees  above  normal.  My 
experience  is,  that  in  general  paralysis  in  the  earlier 
stages  there  is  very  little,  if  any,  increase  in  tempera- 
ture, except  in  the  acute  cases.  About  the  period  of 
the  onset  of  fits  there  is  a  tendency  to  irregular 
increases ;  before,  during,  and  after  fits,  the  tempera- 
ture may  be  high.  Between  the  fits  the  temperature 
may  be  normal,  but  not  uncommonly  there  is  a 
tendency  to  increased  temperature  at  night,  and  all 
excitement,  whether  bodily  or  mental  at  this  time,  is 
associated  with  increase  of  temperature.  The  tempera- 
ture varies  irregularly,  and  I  believe  in  many  cases 
the  irregularity  depends  on  some  intercurrent  trouble. 
It  is  certain  that  with  bed-sores  and  with  local  lung 
inflammations  there  occurs  increase  of  temperature. 
In  the  later  part  of  the  disease,  if  uncomplicated,  the 
temperature  of  the  morning  is  about  100°,  and  of  the 
evening  101°  to  102°,  and  if  any  further  increase  occur 
it  is  well  to  be  on  the  look-out  for  some  physical 
trouble  likely  to  terminate  the  case.  In  a  few 
extreme  cases  I  have  met  with  sub-normal  tempera- 
tures, so  that  the  thermometer  has  registered  only  96° 
or  97°.  Accidental  circumstances  may  cause  sudden 
and  marked  increase  of  temperature,  as  was  seen  in 
the  case  I  have  described,  in  which,  with  haemorrhage 
into  the  cervical  region  of  the  cord,  great  increase  of 
temperature  took  place.  Most  of  the  fits  in  general 
paralysis  are  associated  with  sweating,  which  may 
be    partial,    or    unilateral,   or    general  ;    the    extreme 


Chap.  XII.]  Mental  Symptoms.  337 

amount  of  sweating  whicli  may  occur  is  only  to  be 
appreciated  when  once  seen.  I  have  frequently  seen 
the  development  of  sudamina  within  a  few  hours  of  a 
fit.  With  the  sweating,  the  temperature  of  the  body 
rapidly  falls.  Having  taken  sphygmographic  tracings 
of  hundreds  of  cases  of  general  paralysis,  I  have  come 
to  the  conclusion  that  there  is  no  special  fulse  which 
can  be  said  to  be  in  any  way  associated  with  this 
disease.  In  a  few  the  left  ventricle  acts  with  undue 
vigour,  as  if  to  overcome  some  general  resistance 
to  the  circulation,  and  in  a  few  distinctly  febrile 
symptoms  are  present ;  but  the  pulse  trace  pointed  to 
nothing  which  can  be  in  any  way  looked  upon  as 
characteristic  in  most  cases  of  general  paralytics. 

The  urine  again,  which  was  carefully  examined 
by  Dr.  Crichton  Browne,  varies  extremely  from 
a  specific  gravity  of  I'OIO  to  one  of  1*035.  In 
the  majority  of  cases  I  found  there  was  excess  ot 
phosphates,  and  that  chlorides  might  be  reduced  in 
quantity,  and  that  urea  was  abundant,  but  uric  acid 
not  in  excess.  It  is  extremely  difiiciilt  to  speak  of 
the  quantity  which  may  be  passed,  especially  in  the 
later  stages  of  the  disease,  for  the  patients  becoming 
wet  and  dirty  their  excretions  cannot  be  collected. 
Albumin  is  very  rarely  present. 

Mental  symptoms.— The  signs  of  general  paraly- 
sis are  simply  evidences  of  progressive  mental  weaken- 
ing ;  and  in  acute  alcoholism  one  sees  produced  tem- 
porarily every  shade  of  mental  symptom  which  may  be 
seen  more  permanently  in  general  paralysis.  Earliest, 
we  meet  with  loss  of  self-control,  and  latest,  we  come 
to  loss  of  all  bodily  fower  ;  emotional  disturbance  is 
common,  patients  becoming  lachrymose  and  lustful; 
the  will  is  feeble  and  uncertain,  driving  the  patient 
headlong  in  one  direction,  only  the  next  moment  to 
carry  him  in  the  opposite.  His  senses  may  be  per- 
verted, but  hallucinations  are  not  so  common  among 
w — 14 


33S     Insanity  and  Allied  Neuroses.    [Chap.  xii. 

general  paralytics  as  among  most  of  the  other  types  of 
insanity.  The  symptom  by  which  general  paralysis 
has  been  best  recognised  is  that  of  exaltation  or  of 
grandeur ;  and  although  ideas  of  power  and  influence 
are  met  with,  as  we  have  seen  under  other  conditions, 
yet  there  is  something  almost  characteristic  in  the 
great  ideas  of  the  general  paralytic.  The  patient  is 
altogether  exuberant ;  he  is  prepared  for  any  emer- 
gency :  at  one  moment  saying  he  is  a  king,  and  at 
the  next  an  inventor  ;  in  one  breath  claiming  the 
queen  for  his  wife,  and  in  the  next  prepared  to  add 
all  the  duchesses  to  his  harem.  There  is  a  strange 
benevolence  in  most  of  these  cases  ;  they  are  only  too 
anxious  to  share  their  wealth  and  blessings.  The 
exaltation  may  assume  many  forms,  one  of  the 
simplest  being  represented  by  the  patients  who  tell 
you  they  are  "  all  right,"  and  such  patients  will 
tell  you  they  are  as  well  as  ever  they  were, 
though  unable  to  stand.  Another  class  is  chiefly  con- 
cerned about  meals,  and  although  a  patient  is  having 
the  most  ordinary  diet  he  will  tell  you  his  meal 
consists  of  whale  cutlet  and  stufled  elephant.  Such 
patients  may  appreciate  the  folly  of  a  neighbour,  but 
fail  to  see  anything  peculiar  in  their  own  ideas. 
Thus,  I  have  heard  the  following  conversation  between 
two  general  paralytics  :  "I  am  king  of  England," 
said  one ;  the  other,  turning  with  a  scornful  laugh  to 
me,  said,  "That  man  says  he  is  king  of  England  ;  I  am 
God  Almighty,  and  I  don't  know  him."  In  the  same 
way  I  have  known  a  medical  paralytic  recognise  the 
disease  in  others  by  th-e  very  symptoms  from  which 
he  was  suffering  himself. 

Grandeur  of  ideas  loith  benevolence  is  the  chief 
characteristic  of  the  exaltation  of  general  paralysis. 
The  patients  think  happily,  they  talk  happily,  they 
write  happily,  and  are  altogether  inconsistent  till 
the  weak-mindedness    which    comes  on,    leaves  them 


Chap.  XII.]  DiA GNOSIS.  339 

demented,  although  possibly  still  automatically  mut- 
tering of  their  past  glories.  Yoisin  says  that  the 
melancholia  which  may  be  present  with  general 
paralysis  has  generally  a  hypochondriacal  form,  there 
being  three  marked  varieties,  namely,  the  ideas  of 
obstruction  of  the  organs,  the  denial  of  existence,  and 
the  idea  of  reduction  in  size,  what  in  fact  has  been 
called  micromania.  The  hypochondriacal  insanity  is 
thus  described  by  Dr.  Yoisin  :  The  paralytic  hypochon- 
driac has  some  ideas  which  are  rarely  met  with 
outside  general  paralysis ;  which  are,  in  fact,  supremely 
absurd  and  appear  suddenly ;  he  is  unstable,  and  that 
is  what  brings  about  a  delirium  nearly  resembling 
general  paralysis.  If  the  mental  symptoms  are  those 
of  dementia,  the  symptoms  are  in  no  way  special,  one 
part  of  the  mind  seeming  to  suffer  more  in  one  case 
than  in  another,  till  the  disease  so  far  advances  as  to 
reduce  the  patient  to  a  condition  of  complete  dementia 
similar  to  that  met  with  in  the  last  stages  of  the  other 
mental  disorder. 

Diagpnosis. — The  fatal  nature  of  this  disease 
makes  it  of  the  utmost  importance  that  a  definite 
diagnosis  should  be  made,  and  I  shall  point  out 
several  sources  of  error,  premising  by  saying  that, 
after  twelve  years'  experience  in  Bethlem,  I  find  the 
utmost  difiiculby  in  tracing  the  probable  result  not 
only  in  cases  of  hypochondriasis  with  melancholic 
symptoms,  but  in  cases  of  maniacal  excitement  in 
middle-aged  men.  There  is  not  one  single  patho- 
gnomonic symptom  of  this  disease,  and  in  deciding, 
one  must  form  one's  judgment  by  taking  the  history 
and  the  symptoms  together. 

Alcoholism^  acute  or  chronic,  is  probably  the  most 
common  cause  of  error.  General  paralysis  may  result 
from  alcohol,  or  alcoholism  may  accompany  general 
paralysis.  The  diagnosis  must  depend  upon  the  other 
physical  symptoms  and  on  the  history.     The  man  who 


340       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

is  an  habitual  drunkard,  and  who  has  been  led  into  an 
acute  debauch,  suffers  from  gastric  disturbance  or 
sleeplessness,  and  has  no  inequality  of  pupils,  no  change 
in  his  reflexes,  no  greasiness  of  skin,  is  probably  suffer- 
ing from  alcoholism  and  not  from  general  paralysis  ; 
time  alone  will  clear  up  to  a  certainty  his  condition. 
The  same  difficulty  has  arisen  from  lead  poisoning,  only 
there  the  history  and  the  blue  line,  with  possibly  some 
affection  of  the  extensor  muscles  of  the  fore-arm,  will 
enable  you  to  form  a  diagnosis  ;  although  I  believe  lead 
poisoning,  like  alcohol,  may  produce  general  paralysis. 

In  my  experience,  the  most  difficult  cases,  after 
these  with  alcoholism,  are  those  suffering  from  cJironic 
maniacal  excitement,  and  I  have  frequently  to  retain 
such  patients  for  months,  without  being  able  to 
satisfy  myself  as  to  the  diagnosis.  They  are  restless, 
excited,  loquacious,  joyous,  and  boastful,  and  with 
exaltations  they  may  even  be  benevolent,  but  more 
frequently  they  are  aggressive.  Their  appetites  after 
the  earliest  stage  of  sleeplessness  become  enormous  ; 
there  may  be  tremor  of  tongue  and  lips ;  the  pupils 
are  generally  equal ;  the  complexion  is  sallow  and 
leathery ;  but  the  face  keeps  thin,  and  there  is  little 
or  no  loss  of  expression ;  there  is  no  tendency  to  fits  ; 
the  patients  are  destructive  to  their  clothes,  fre- 
quently pull  out  their  hair,  and  are  noisy  and  de- 
structive at  night.  There  is  not  the  same  tendency 
to  remission  or  to  get  fat  which  is  common  in  general 
paralysis  with  a  maniacal  onset.  In  such  cases 
blistering  of  the  scalp  has  resulted  in  cure  in  many 
cases,  and  in  others  the  symptoms  have  become  fixed, 
constant  chatter  of  an  incoherent  kind  persisting. 

Syphilis  may  produce  mental  and  bodily  dis- 
orders hardly  to  be  distinguished  from  general  para- 
lysis, and  probably  it  also  causes  one  form  of  the 
disease.  In  the  first  place  there  may  be  thick- 
enings of  the  arteries  due   to  the  syphilis  leading  to 


Chap.  XII. 1       PoST-APOPLECTlC  DEMENTIA.  34T 

dementia,  and  but  for  the  history  I  do  not  know  any 
means  of  distinguishing  the  one  class  from  the  other, 
for  anti-syphilitic  treatment  often  fails  to  have  any 
effect  whatever.  Gummata,  if  they  happen  to  cor- 
respond with  the  motor  areas  of  the  brain,  similarly 
produce  symptoms  resembling  general  paralysis,  and 
the  only  points  beyond  the  history  of  importance  are 
the  greater  frequency  of  headache  with  syphilis,  and 
the  much  greater  tendency  to  strabismus  and  ptosis, 
followed,  if  the  case  be  progressive,  by  hemiplegia ;  there 
may,  in  addition,  be  facial  paralysis,  or  some  marked 
paralysis  of  a  cranial  nerve,  or  loss  of  one  or  more 
special  sense.  Treatment  will  in  some  cases  clear  up, 
as  in  the  following  :  John  Charles  P.,  married,  set. 
34,  clerk,  admitted  October  2nd,  1883,  no  insane 
relations ;  first  attack  lasted  three  months.  He  had 
been  somewhat  intemperate ;  suffered  from  syphilis  ; 
was  suspicious,  and  thought  people  were  going  to  murder 
him  ;  was  unable  to  look  after  his  business  ;  thought  he 
had  swallowed  a  button,  which  caused  him  great  bodily 
suffering;  he  tried  to  choke  his  wife  and  to  cut  his 
own  throat.  After  admission  he  was  noticed  to  have 
marked  ptosis,  external  strabismus,  and  dilatation 
of  right  pupil ;  was  dull  and  obstinate,  wet  and  dirty. 
Ophthalmoscopically  the  right  eye  showed  choroido- 
iritis,  with  patches  of  atrophy  and  masses  of  pigment. 
The  treatment  by  perchloride  of  mercury  was  followed 
by  satisfactory  results,  and  he  was.  discharged  re- 
covered. 

In  old  patients  it  is  often  difficult  to  decide, 
for  progressive  weak-mindedness  is  common  as  a 
result  of  senile  changes ;  and,  on  the  other  hand, 
excesses  in  old  patients  may  produce  general  paralysis, 
which  runs  a  similar  course  to  that  seen  in  younger 
patients. 

Post- apoplectic  dementia  may  be  mistaken  for 
dementia  following  the  fits  of  general  paralysis,  and 


34^       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

this  is  sometimes  hardly  to  be  distinguished,  except 
from  the  fact  that  with  apoplexy  the  paralysis  is 
more  permanent,  leaving  the  patient  for  weeks  hemi- 
plegic,  so  that  there  may  be  pronounced  weakness  of 
one  limb  or  another  long  after  recovery  from  other 
symptoms,  while  fits  of  general  paralysis  occurring  in 
an  old  man  will  leave  him  very  little  the  worse  in 
body,  although  vastly  deteriorated  in  mind. 

Some  forms  of  tuinour  affecting  the  brain  may 
lead  to  suspicions  of  general  paralysis,  and  I  am 
inclined  to  think  that  implication  of  the  frontal  lobes 
by  any  growth  may  cause  grave  doubts,  and  unless 
headache,  or  some  local  nerve  palsy  occur,  the  case 
may  be  diflS.cult  to  diagnose.  I  have  seen  hydatids 
affecting  the  frontal  regions,  produce  anomalous  mental 
symptoms  not  cleared  up  till  after  death. 

Epilejosy  may  end  in  weak-mindedness,  but  the 
frequency  of  the  fits,  with  the  comparatively  slight 
loss  of  mental  power  following  epileptic  fits,  dis- 
tinguish them  from  those  of  general  paralysis.  I  can 
understand  that  disseminated  sclerosis  may  produce 
symptoms  of  weak-mindedness,  tremulousness,  hesi- 
tation of  speech,  fits,  and  the  like ;  but  I  have  only 
seen  one  case  in  Bethlem,  and  in  this,  the  age, 
the  irregularity  of  the  symptoms,  the  nystagmus, 
and  the  tremor  of  hands  and  head  cleared  up  the 
diagnosis. 

Other  possible  fallacies  have  been  suggested,  and 
Dr.  Mickle,  in  addition  to  the  above,  gives  dementia 
with  other  forms  of  paralysis,  senile  dementia,  senile 
dementia  with  paralysis,  locomotor  ataxy,  paralysis 
agitans,  chronic  generalised  palsy  (such  cases  prob- 
ably may  be  general  paralysis  without  mental  symp- 
toms), other  forms  of  acute  or  chronic  paralysis,  acute 
ascending  paralysis,  tremors  of  age,  and  simple  speech 
defect. 

What     has    already    been    said    will    suffice    to 


Chap.  XII.]  Prognosis.  343 

distinguish  general  paralysis  of  the  insane  from  condi- 
tions nearly  allied  to  it. 

Prognosis. — As  soon  as  it  is  definitely  settled 
that  a  patient  is  suffering  from  general  paralysis  of 
the  insane,  the  prognosis  is  really  made. 

No  such  case,  as  I  have  said,  when  fully  established, 
ever  recovers  ;  remissions  occur,  but  not  cures  ;  in  some 
cases,  however,  the  disease  runs  a  much  slower  course 
than  in  others.  My  own  experience  agrees  in  the 
main  with  writers  who  say  that  the  average  duration 
of  a  case  of  established  general  paralysis  is  three  years. 
By  this  one  means  that  as  soon  as  the  speech,  the 
pupils,  and.  the  gait,  together  with  signs  of  mental 
decay,  show  themselves,  three  years  would,  almost  cer- 
tainly see  the  fatal  conclusion  of  the  case.  In  my  ex- 
perience cases  of  simple  general  paralysis  without 
marked  mental  symptoms  live  much  longer  than  those 
in  which  there  is  both  bodily  and  mental  degeneration. 
The  disease,  as  far  as  prognosis  is  concerned,  must 
be  considered  from  the  maniacal,  melancholic,  and 
demented  sides.  With  acute  mania  a  prospect  of  re- 
mission exists ;  so  that  in  most  cases  the  general  para- 
lytic, with  ambitious  mania  and  restlessness  after 
a  few  months'  treatment,  becomes  rapidly  quiet, 
and  remains  so  for  joeriods  varying  from  a  month 
to  over  a  year  before  a  return  of  excitement  or  of 
convulsive  seizures,  which  may  rapidly  produce  a  fatal 
ending.  With  melancholic  general  paralysis  the 
progress  is  pretty  uniform,  and  I  think  rarely  lasts 
two  years.  With  simple  progressive  dementia  the 
symptoms  may  last  for  several  years.  In  nearly  all 
cases  the  prognosis  is  influenced  by  the  body  tempera- 
ture and  by  the  occurrence  of  fits,  so  that  a  patient  who 
has  a  temperature  constantly  over  100'^  will  probably 
rapidly  sink,  and  a  patient  with  constant  recurrence 
of  fits  will  likewise  probably  die  early.  In  women 
the    disease   is    not,    as    a    rule,    so    rapid    as    with 


344       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

men.  The  early  occurrence  of  bed-sores,  abscesses,  or 
lung  com]Dlications  tends  greatly  to  the  increase  of 
danger.  Patients,  who  after  the  acute  stage  rapidly 
become  fat,  run  a  great  risk  of  early  and  severe  fits. 
There  is  danger,  as  I  have  said,  from  local  injuries,  the 
blood  appearing  to  be  in  a  very  unhealthy  condition, 
and  septicaemia  may  result  from  comparatively  slight 
injuries. 

Treatment. — To  attempt  to  treat  a  disease  which 
one  recognises  to  be  incurable  is,  to  say  the  least  of  it, 
unsatisfactory ;  but  something  must  be  done,  and  one 
hopes,  from  time  to  time,  that  something  may  be  dis- 
covered which  may  possibly  arrest  this  disease  in  its 
earliest  stages.  I  have  tried  every  variety  of  medi- 
cine, new  and  old,  which  has  been  recommended  for 
nervous  diseases.  Years  ago  the  virtues  of  physo- 
stigma  were  sung,  and  still,  for  want  of  anything 
better,  I  am  in  the  habit  of  ordering  that  drug  in 
small  doses,  and  I  can  only  say  that  I  have  never  seen 
it  do  any  harm,  and  a  few  patients  seem  to  have  im- 
proved while  being  treated  with  it.  The  old  treatment 
was  by  means  of  counter-irritation  applied  to  the 
scalp  and  to  the  spinal  column,  blisters  or  cauteries 
being  the  favourites.  I  have  used  setons  and  blisters 
with  but  little  satisfaction.  In  a  few  doubtful  cases 
improvement  has  taken  place,  and  the  case  which  I 
have  already  referred  to  as  relieved  by  the  occurrence 
of  a  huge  carbuncle,  impelled  me  once  more  to  try  the 
effect  of  setons  and  treatment  of  this  description, 
but  with  little  effect. 

In  my  opinion,  the  general  paralytic  requires, 
above  all  things,  to  be  removed  from  his  home  and 
surroundings,  and  to  be  fed  with  light,  rather  unstimu- 
lating  food,  and  to  have  sufficient,  but  not  exhausting 
out-door  exercise.  Return  to  home  is  one  of  the  most 
certain  things  to  produce  a  relapse,  and  in  the  case 
of  many  of   the  general  paralytics  who  have  passed 


Chap.  XII.]  Pathology.  345 

through  my  hands,  and  about  whom  I  have  had  some 
doubts,  the  diagnosis  has  been  cleared  up  at  once 
when  their  friends  have  insisted  upon  trying  them  at 
home.  Any  excess  acts  disastrously,  and  I  believe 
that  this  statement  may  even  be  extended  by  saying 
that  general  paralytics  are  extremely  susceptible  to  the 
influence  of  powerful  drugs.  In  cases  where  extreme 
violence  with  destructiveness  was  present,  I  tried 
hyoscyamine,  but  found  it  necessary  to  give  that  drug 
with  extreme  caution,  as  one-twentieth  part  of  a  grain 
would  produce  alarming  symptoms  of  collapse.  I 
have  refrained  for  some  time  from  giving  any  powerful 
drugs  of  that  kind,  for  fear  of  doing  harm  by  shaking 
further  the  tottering  physical  edifice. 

Pathology. — To  treat  satisfactorily  the  pathology 
of  general  paralysis  of  the  insane,  one  requires  a 
large  amount  of  space,  and  very  elaborate  diagrams 
with  descriptions ;  even  then,  as  the  points  of  most 
importance  are  not  definitely  fixed,  the  result  would 
be  but  tentative;  I  shall,  therefore,  content  myself 
with  giving  a  general  outline  of  my  experiences. 

The  scalp  is  generally  thick  and  hairy,  the  calva- 
rium  often  deeply  marked  by  pacchyonian  bodies,  which 
often  occur  in  great  excess,  the  dura  mater  being  com- 
monly adherent  in  patches  at  the  vertex  ;  the  dura 
mater  itself  is  rarely  much  thickened  ;  there  may  be 
in  its  inner  surface  ferruginous  stainings,  and  I  have 
seen  one  case  in  which  three  convulsive  fits  were  re- 
presented by  three  thin  films  resting  on  the  dura 
mater  of  different  shades  of  red-brown;  these  stainings 
may  occupy  either  the  whole  of  the  inner  surface,  or 
they  may  occupy  one  complete  half,  or  half  of  the  base. 

Occasionally    one    meets    with    false    membranes, 
occupying   the   whole    or   half    of  the  vertex   imme-. 
diately  under  the  dura  mater,  as  seen  in  the  annexed 
illustration    (page    346).      This    false    membrane    is 
due   to  pachymeningitis,  and   may  vaiy  in  thickness 


34^      Insanity  and  Allied  Neuroses.  [Chap.  xii. 

and  consistency.  In  one  case  I  have  seen  the  greater 
part  of  it  converted  into  a  hard  cartilaginous  cap, 
resembling  a  second  calvarium.  In  other  cases  I 
have  found  it  a  felt-like  mass,  with  or  without  local 
haemorrhages  into  its  substance.  These  membranes 
may  occur   in    very   old   or  in    ordinary    cases,    and 


Pachymeningitis . 

there  is  no  relationship  between  them  and  the  dura- 
tion of  the  disease.  On  removal  of  the  dura  mater, 
and  a  false  membrane  if  it  be  present,  the  arach- 
noid will  be  found  to  exhibit  a  certain  number  of 
milky  spots,  and  there  will  be  almost  always  a  con- 
siderable amount  of  subarachnoid  fluid.  This  may  be 
most  visible  over  particular  areas,  so  that  there  are 
lakelets  of  fluid  taking  the  place  of  wasted  convolu- 
tions, the  convolutions  most  commonly  affected  being 
the  ascending  parietal,  paracentral,  and  base  of  the 


Chap.  XII.]  Pathology.  347 

first  frontal.  On  attempting  to  remove  the  membranes, 
adhesions  may  occur.  At  one  time  it  was  invariably 
accepted  that  adhesions  were  sure  to  be  present,  but  a 
change  has  come  over  the  general  opinion,  and  now-a- 
days  it  is  admitted  that  general  paralysis  in  an 
advanced  condition  may  occur,  and  yet  no  adhesions 
be  found. 

Adhesions,  if  present,  vary  considerably  in  their 
extent  and  site ;  they  may  occur  chiefly  on  one  side ; 
they  may  occur  at  the  base  of  the  first  frontal ;  they 
may  be  present  along  the  centre  of  the  convolutions,  or 
attached  to  their  margins.  Adhesions  occur  most 
commonly  over  the  frontal,  parietal,  and  temporo- 
sphenoidal  lobes,  with  occasional  patches  scattered 
over  the  rest  of  the  brain  ;  they  are  most  common  on 
the  superior  surface,  but  they  may  also  be  present  on 
the  inferior.  They  may  occur  in  acute  cases,  and 
may  be  readily  separable,  or  they  may  be  so  universal 
that  an  attempt  to  remove  the  membranes  causes 
a  peeling  off  of  the  grey  matter  with  them.  There 
is  generally  a  considerable  amount  of  fluid  in  the 
lateral  ventricles;  but  this  varies  to  a  great  extent, 
so  that  in  some  cases,  with  a  small  amount  of  fluid 
in  the  membranes,  much  is  found  in  the  ventricles 
giving  rise  to  an  appearance  of  hydrocephalus.  In 
such  cases,  post  imoi^te^n,  a  great  deal  of  softening  of  the 
brain  tissue  about  the  ventricles  is  found  ;  on  section 
the  brain  is  generally  firm,  unless  this  excess  of  fluid  be 
present ;  so  that  the  brain  examined  two  or  three  days 
after  death  will  be  found  to  cut  like  a  cheese  ;  the 
grey  matter  may  be  thin,  but  not  uncommonly  there 
is  nothing  specially  noteworthy  in  it.  In  some  cases, 
however,  two  or  three  zones,  varying  in  tints,  are  very 
distinct  in  the  grey  matter.  I  have  never  found  any 
miliary  aneurisms  in  such  cases ;  the  vessels  at  the 
base  may  be  extremely  atheromatous;  the  capillaries 
may,  on  examination,  be  found  to  be  much  twisted  or 


348       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

kinked,  with  quantities  of  leucocytes  in  their  sheaths ; 
and  blood  crystals  may  also  be  present. 

In  the  spinal  cord  there  may  be  considerable 
wasting  with  excess  of  subarachnoid  fluid,  adhesion 
of  membranes  to  surface,  and  local  or  general  pachy- 
meningitis. There  may  be  spicules  of  bone  in  the 
arachnoid  scattered  all  over  the  surface  ;  effusion  of 
blood  may  occur  within  the  dura  mater,  associated 
with  epileptiform  fits. 

The  minute  changes  which  may  occur  in  the 
nervous  tissues  are  considerable,  and  affect  three 
tissues  specially,  the  connective  tissue,  the  capillaries, 
and  the  nerve  cells.  In  early  general  paralysis  there 
is  commonly  excessive  growth  of  connective  tissue, 
there  being  a  large  number  of  Deiter's  cells  scattered 
throughout  the  tissue;  these  are  most  marked  in  the 
superficial  layers  of  brain  and  cord. 

The  capillaries  have  unduly  prominently  marked 
nuclei,  with  other  changes  pointing  to  inflammatory 
action;  from  the  perivascular  sheath  processes  of  con- 
nected tissue  may  ramify;  the  perivascular  sheath 
itself  may  be  crammed  with  leucocytes,  and  I  have 
seen  parallel  rows  of  escaped  leucocytes  near  the  vessel 
walls.  The  connective  tissue,  which  in  the  earlier 
stages  is  partly  loose  and  transparent,  in  the  latter 
stages  becomes  firm  and  contracted.  The  nerve  cells 
are  afiected  in  various  degrees,  the  pyramidal  cells  of 
third  layer  suffering  most ;  these  lose  their  processes 
first,  and  swell,  the  nucleolus  often  being  very  marked 
and  appearing  as  a  bright  spot ;  the  nucleus  becomes 
large,  granular,  and  at  times  pigmented.  The  cell  wall 
may  burst,  or  in  some  cases  may  contract  round  the 
nucleus,  leaving  a  pericellular  space  of  irregular  out- 
line. I  have  seen  this  space  filled  with  coloured 
debris  from  the  degenerated  nucleus.  The  other  cells 
may  become  swollen  or  granular,  and  scattered  among 
these  cells  various  foreign  bodies  may  be  present,  some 


Chap.  XII.]       The  Sympathetic  System.  349 

being  of  irregular  size  and  rounded  outline,  faintly- 
staining  with  logwood,  homogeneous  in  structure, 
having  the  general  aspect  of  stained  serum.  Some 
other  bodies  seem  to  be  the  result  of  broken-down 
nerve  tissue,  and  a  very  large  number  of  bodies,  called 
miliary,  are  the  result  of  methods  of  hardening. 

In  the  spinal  cord  the  changes  are  of  three  dif- 
ferent kinds  :  general  wasting,  in  which  all  the  tissues 
seem  equally  affected ;  secondly,  cases  in  which  the 
posterior  columns  are  mainly  implicated  ;  and  thirdly, 
the  cases  in  which  the  lateral  columns,  or  the  lateral 
and  anterior,  suffer. 

Of  the  second,  it  is  only  necessary  to  say  that  the 
changes  resemble  those  which  occur  in  locomotor 
ataxy,  and  may  consist  of  changes  in  the  radicular 
fasciculi ;  or  the  lateral  posterior  column  may  be  the 
one  which  is  chiefly  affected. 

In  the  third  group  the  changes  are  of  a  kind 
which  has  been  described  as  secondary  lateral  sclerosis, 
or  Turck's  paralysis. 

As  with  the  brain,  so  with  the  cord,  the  three 
tissues  may  become  affected,  the  connective  tissue, 
vessels,  and  nerve  tissue,  each  being  affected  in  a 
similar  way  to  that  of  the  brain.  The  central  canal, 
which  is  always  referred  to  when  speaking  of  changes 
in  the  spinal  cord,  may  present  almost  any  variety  of 
change ;  at  one  time  the  canal  being  filled  with  debris, 
and  at  another  there  being  excessive  proliferation  of 
the  epithelium,  in  another  the  whole  region  may  be 
represented  by  an  aggregation  of  cells  and  granules, 
which  deeply  stain  with  logwood.  In  some  cases  the 
canal  is  of  great  size,  and  in  others  it  is  all  but 
obliterated. 

Sympathetic  system. — In  the  changes  in  general 
paralysis  of  the  insane,  one  part  of  the  nervous 
system  after  another  has  been  looked  upon  as  the 
starting-point  of   the  disease  \     and  it   is  not   to    be 


350       Insanity  and  Allied  Neuroses.  [Chap.  xii. 

wondered  at  that  the  sympathetic  system  should  have 
been  blamed.  Two  French  writers,  Bonnet  and 
Poincare,  think  they  have  found  the  source  of  general 
paralysis  in  degenerative  changes  occurring  in  the 
sympathetic  ganglia  of  the  neck.  I  have  carefully 
examined  sections  from  these  regions  in  many  cases  of 
general  paralysis,  and  I  can  only  say  that  I  have 
found  absolutely  nothing  characteristically  patho- 
logical. That  many  cells  are  granular  and  contain 
pigment  is  nothing  unusual ;  and  I  must  repeat  that  T 
have  hitherto  failed  to  detect  evidences  of  disease  in 
the  cervical  ganglia. 

Changes  have  been  found  in  the  nerve  trunks 
generally,  and  this  is  but  confirmation  of  the  state- 
ment that  general  paralysis  is  a  degeneration  which 
may  afiect  all  parts  of  the  nervous  system. 

To  sum  up,  the  pathological  changes  which  I  have 
found  are  either  the  results  of  premature  decay  and 
local  wasting,  or  are  due  to  a  process  which  must 
be  considered  as  allied  to  inflammation,  although  the 
term  inflammation  can  hardly  be  used  for  a  process 
which  may  extend  over  years.  The  changes  may 
occur  primarily  in  brain,  cord,  or  peripheral  nervous 
system,  for  although  I  can  give  no  cases  of  paralysis 
by  propagation  to  make  one  believe  in  the  propagation 
of  a  diseased  process  from  the  periphery  to  the  centre, 
yet  evidence  is  not  wanting.  In  general  paralysis,  as 
I  have  said,  other  organs  may  sufier ;  the  blood  may 
become  unstable  and  prone  to  rapid  change ;  the 
arteries  may  be  affected  in  several  ways ;  and  the 
kidneys  may  likewise  suffer,  primarily,  or  through  the 
arteries. 


351 


CHAPTER  XIIT. 

PARALYTIC     INSANITY. 

Insanity  associated  with  paralysis,  other  than  general  paralysis  of 
the  insane — Apoplexy — Paralysis  agitans — Locomotor  ataxy. 

Insanity  following"  apoplexy. — This  division  is 
one  in  which  I  shall  place  several  varieties  of  mental 
disorder  associated  with  conditions  of  physical  weak- 
ness due  to  changes  iji  the  nervous  system. 

It  is  one  of  the  most  striking  evidences  of 
the  close  relationship  which  exists  between  mind 
and  brain,  that  serious  damage  to  a  brain,  such 
as  that  following  from  apoj^lexy,  rarely  allows  of 
perfect  intellectual  recovery  ;  and  that  just  as  a  scar 
remains  as  the  evidence  of  an  old  wound,  so  change  in 
disposition,  or  loss  of  memory,  may  be  the  intellectual 
scars  left  by  apoplexy.  The  lesions  take  place  at  the 
base,  not  the  surface  of  the  brain. 

Every  variety  of  weak-mindedness  may  be  the  result 
of  apoplexy ;  for  instance,  I  have  known  a  man,  who 
formerly  was  a  fluent  speaker,  recover  with  an  ability 
to  write  and  to  understand  as  well  as  ever,  but  with 
inability  to  express  himself  with  freedom  of  speech. 
Probably,  emotional  instability  is  the  most  cominon 
result  of  apoplexy,  the  person  becoming  loquacious, 
irritable,  and  tearful.  These  slight  perversions  may 
have  no  direct  interest  to  the  asylum  physician  unless 
they  develop  beyond  moderate  bounds ;  but  still,  in 
them  must  be  recognised  the  earlier  stages  of  a  dis- 
eased process.  The  loss  of  memory,  irritability,  and 
loss  of  self-control  may  render  it  necessary  to  seclude 
patients ;    and  I  have  seen  several    important  trials 


352      Insanity  and  Allied  Neuroses.  [Chap.  xiii. 

as  to  the  validity  of  wills  turn  upon  the  degree  of 
mental  weakness  exhibited  by  a  patient  after  apoplexy. 
The  loss  of  memory  may  be  so  extreme  that  a  patient 
is  not  responsible  one  moment  for  what  he  did  the 
moment  before ;  or  a  man  may  be  so  emotional  that 
slight  influence  from  without  must  be  acknowledged  to 
be  undue  influence  and  sufiicient  to  invalidate  a  will. 

Of  all  symptoms  following  apoplexy^  aphasia,,  asso- 
ciated usually  with  right-side  paralysis,  appeals  most 
strongly  to  the  minds  of  laymen ;  and  I  have  known 
at  least  one  patient  considered  to  be  insane  by  a  jury 
because  he  was  unable  to  express  himself  in  words, 
the  jury  being  fully  convinced  that  a  man  who  made 
unintelligible  noises,  when  asked  a  plain  question,  must 
be  a  fool.  About  the  same  time  as  the  above  inquisi- 
tion was  held,  a  jury  accepted  the  fact  that  a  man, 
who  had  recently  died,  might  have  been  of  sound  mind 
although  aphasic,  and  his  will  was  held  good,  the  two 
cases  showing  how  diflS.cult  it  is  to  impress  a  jury 
with  the  essentials  of  a  condition  like  aphasia  ;  when 
the  aphasic  patient  is  before  the  jury,  their  common 
sense,  so-called,  overrides  an  expert's  opinion.  I  would 
say,  in  reference  to  this  subject,  that  aphasia  may 
exist  to  almost  any  degree,  yet  there  may  be  sufficient 
mental  power  to  transact  all  the  business  of  life  sanely 
and  satisfactorily. 

The  cases  of  insanity  following  apoplexy  divide 
themselves  into  those  with  excitement,  those  with 
depression,  and  those  with  simple  weak-mindedness,  the 
majority  of  the  cases  being  weak-minded  from  the  first, 
but  the  dementia  becoming  more  and  more  profound. 
The  apoplexy  may  be  the  result  of  senile  softening,  or 
of  true  hsemorrhagic  effusion.  In  the  former  state  we 
rarely  have  patients  admitted  into  Bethlem,  though 
such  cases,  I  believe,  are  not  uncommon  in  county 
asylums,  where  patients  live  for  many  years,  and  die 
of  old  age  with  its  degenerations. 


Chap.  XIII.]  Dementia  following  Apoplexy.      353 

Apoplexy  in  the  following  case  was  dependent  on 
brain  softening ;  it  occurred  in  a  case  of  chronic  in- 
sanity, and  was  associated  with  considerable  amount 
of  excitement :  Jane  W.,  married,  set.  83,  admitted 
into  Bethlem  in  September,  1857,  when  60  years 
old,  with  the  idea  that  people  were  conspiring  against 
her ;  her  mental  derangement  was  attributed  to  a 
law  affair.  She  was  a  quiet,  industrious  old  patient 
till  the  apoplexy  preceding  her  death.  In  November, 
1876,  she  fell  down  insensible,  but  soon  regained 
mental  power,  still,  however,  suffering  from  left 
hemiplegia.  For  the  next  few  months  she  remained 
in  bed,  at  times  being  quiet  and  sensible,  in  fact 
more  sensible  than  she  had  been  for  years  ;  but  during 
the  night,  and  at  other  irregular  intervals,  she  was 
violent  and  noisy,  sometimes  screaming  for  hours 
together.  She  said  she  felt  herself  falling  through 
the  bed  and  floor,  and  gave  this  as  the  reason 
for  her  excitement.  She  sank  and  died  in  the  middle 
of  January  of  the  same  year.  Post-mortem :  the 
brain,  which  weighed  38  oz.,  exhibited  consider- 
able wasting  of  the  convolutions,  dura  mater  thick 
and  adherent  to  calvarium,  arachnoid  opaque,  pia 
mater  easily  separable  from  brain,  much  atheroma 
of  vessels  at  base,  a  spot  of  softening  the  size  of  a 
hazel-nut  at  posterior  edge  of  right  thalamus  opticus  ; 
there  was  nothing  abnormal  in  the  rest  of  the  viscera. 
The  above  case  was  of  interest  from  the  fact  that  dis- 
turbance within  the  skull  was  associated  with  chanere 
in  the  mental  symptoms  in  a  person  who,  for  twenty 
years,  had  been  under  observation  in  Bethlem,  there 
being  a  transition  from  comparative  sanity  to  maniacal 
excitement. 

The   next    case    is   a  good    example  of   dementia 
following     apoplexy.        Here     the     patient    suffered 
from    more    than    one    attack    of   apoplexy,   but    did 
not  regain  sanity  after  the  first  attack.      Alfred   D. 
X— 14 


354     Insanity  and  Allied  Iveuroses.  [Chap.  xiii. 

married,  set.  59,  doctor;  both  father  and  mother 
died  of  apoplexy  ;  he  was  sober,  and  had  no  history  of 
other  bodily  illnesses.  He  was  admitted  in  1872. 
Six  months  before  admission  he  had  a  fit,  and  from 
that  time  he  became  childish,  saying  "  yes  "  to  every- 
thing. His  memory  was  so  imperfect  that  he  did  not 
recognise  his  own  name,  and  any  words  he  uttered 
were  incoherent;  at  times  he  would  give  way  to  great 
passion,  and  at  other  times  he  would  appear  melancholy, 
and  burst  into  tears.  Although  feeble,  he  attempted  to 
get  about,  and  he  would  wander  in  an  objectless  way 
from  place  to  place.  In  July  of  the  same  year  he  had 
another  fit,  which  is  described  as  affecting  his  whole 
body.  In  September  following  he  was  found  by  the 
night-watch  on  his  left  side,  and  vomiting,  with  his 
right  arm  over  his  chest  moving  in  a  waving  manner  ; 
he  resisted  if  the  right  side  were  pinched  ;  there  was 
no  reflex  when  a  similar  stimulus  was  applied  to 
the  left ;  pupils  were  small  and  equal,  breathing 
became  more  difficult,  and  he  died  on  the  following 
day.  Post-mortem  :  there  were  several  indejjendent 
apoplexies,  one  affecting  the  left  frontal  lobe,  which  it 
had  excavated ;  both  occipital  regions  bore  scars  and 
old  pigment ;  in  the  right  ventricle  was  a  large  quan- 
tity of  loose  black  clot ;  brain  weighed  50  oz.,  heart 
17  oz.  ;  kidneys  with  small  cysts  and  with  adherent 
capsules  ;  convolutions  of  both  sides  were  flattened 
by  pressure.  In  this  case  an  unusual  number  of  apo- 
plexies occurred  in  one  patient,  and  the  result  was 
simple  progressive  dementia  without  excitement,  the 
course  of  the  disease  being  rather  rapid.  In  such 
cases  as  this  one  would  recommend  that  the  patient 
should  be  kept  at  home  if  possible,  as  the  prospect  of 
life  is  short,  and  the  difficulty  of  managing  a  paralysed 
patient,  especially  if  only  weak-minded,  is  not  extreme  ; 
but,  as  in  this  case,  it  may  happen  that  the  only  place 
open  for  the  patient  is  the  workhouse  or  an  asylum ; 


Chap.  XIII.]  Apoplexy.  355 

I   therefore  felt  justified  in  giving    him   the  benefit 
of  Bethlem. 

Mental  change  immediately  following  an  attack  of 
apoplexy,  which  vjas  followed  hy  a  second  fit  termi- 
nating fatally. — Joseph  L.,  married,  set.  35  ;  no  in- 
sane relations,  a  jewel-case  maker ;  first  attack  of  in- 
sanity attributed  to  over-work,  although  there  is  no 
evidence  as  to  the  nature  of  this  over- work.  The 
patient  was  admitted  into  St.  Thomas's  Home  early 
in  November,  1883,  suffering  from  the  result  of  fits, 
supposed  to  have  been  epileptic.  He  had  been  ex- 
cited, and  fancied  people  were  against  him  ;  said  that 
hands  were  continually  being  placed  on  his  bed  with  a 
view  of  injuring  him  ;  he  repeatedly  got  out  of  bed  to 
catch  these  people.  He  saw  rats  about  his  bed,  and 
said  that  he  was  walking  a  great  many  miles  a  day  on 
business.  His  character  was  said  to  have  been  changed 
ever  since  an  attack  of  fits.  Formerly  he  was  quiet 
and  reserved,  but  now  talkative  and  communicative. 
He  had  attacked  his  friends  ;  he  thought  they  were 
mesmerists  and  conjurers,  who  prevented  him  from 
sleeping,  and  that  his  workshops  were  in  the  hospital. 
Four  days  after  admission  I  found  him  apparently  in 
a  sane  condition,  with  no  sign  of  paralysis  except 
slight  facial  palsy.  His  memory  appeared  perfect, 
and  he  recognised  the  delusions  from  which  he  had 
suffered.  He  made  complaints  of  feeling  cold,  but 
w^ent  to  bed  at  the  usual  time,  and  was  found  dead  at 
4  a.m.  Post-mortem  :  the  membranes  on  right  side 
were  gorged  with  blood,  causing  considerable  flattening 
of  the  convolutions  ;  there  were  evidently  two  periods 
of  haemorrhage,  one  marked  simply  by  blood  staining 
of  a  brownish  colour,  which  merely  stained  the  frontal 
lobes  and  the  first  occipital  lobe,  the  mass  of  blood 
having  been  absorbed  ;  the  second  was  a  large  fresh 
clot,  separating  cortex  from  membranes,  which  had 
escaped  from  right  lateral  ventricle,  the  latter  being 


356     Insanity  and  Allied  Neuroses.  [Chap.  xni. 

filled  with  a  very  large,  fresh,  soft  clot  which  had 
burst  through  the  outer  part  of  the  corpus  striatum. 
Other  parts  of  the  brain  were  healthy,  great  thickening 
and  calcification  of  the  mitral  valves,  and  some  athe- 
roma of  the  aorta.  Here  we  have  a  case  of  arterial 
degeneration  and  apoplexy  in  a  young  man,  there 
being  two  sets  of  fits,  each  represented  by  a  separate 
haemorrhage  ;  the  first  haemorrhage  seems  to  have  been 
slight,  and  to  have  spread  chiefly  over  the  right  frontal 
region,  a  small  quantity  also  affecting  the  occipital 
region  of  the  same  side.  Together  these  haemorrhages 
were  sufficient  to  set  up  all  the  mental  disturbances 
from  which  the  patient  suffered. 

Besides  the  cases  in  which  haemorrhage  or  softening 
set  up  mental  disorder,  there  are  other  cases,  rarely 
seen  except  in  asylums,  in  which  effusions  of  blood 
occur  beneath  the  dura  mater.  I  have  seen  several 
such  cases  in  which  the  appearances  were  misleading. 

These  blood  effusions  are  the  result  of  changes  which 
have  given  rise  to  symptoms  of  general  paralysis  of 
the  insane,  and  are  stages  of  pachymeningitis. 

Paralysis  agitaiis  and  its  relationsliip 
to  insanity  have  been  described  by  Professor  Bail, 
of  Paris,  and  at  the  International  Medical  Congress, 
1881,  he  described  moral  derangement  and  insanity 
as  seen  in  cases  of  paralysis  agitans,  and  he  came  to 
the  following  conclusions  :  That  mental  derangement 
is  more  frequent  in  paralysis  agitans  than  has  been 
generally  supposed  ;  that  in  slighter  forms  the  psycho- 
logical change  is  limited  to  irritability  and  restlessness, 
but  that  in  more  severe  cases  it  amounts  to  positive 
insanity ;  that  three  forms  at  least  of  mental  distur- 
bance may  be  observed  in  such  cases,  the  first  corre- 
sponding to  what  is  called  lypemania  or  melancholia, 
the  second  closely  bordering  on  dementia,  and  the 
third  exhibiting  an  intermittent  or  periodical  charac- 
ter ;  lastly,  that  there  is  in  cases  of  shaking  palsy  no 


Chap.  XIII.]  Locomotor  Ataxy.  357 

distinct  connection  between  the  loss  of  intellectual 
l)OAver  and  the  severity  of  the  pliysical  symptoms.  I 
have  never  had  a  case  in  Bethlem  of  insanity  with 
shaking  palsy,  but  I  have  seen  repeatedly  cases  in 
which  tlie  paralysis  was  distinctly  correlated  to  mental 
weakening,  and  in  the  main  I  would  accept  Professor 
Ball's  observations.  I  have  met  with  insanity  in  the 
children  of  parents  with  paralysis  agitans. 

Insanity  connected  t^  itii  locomotor  ataxy, 
independently  of  general  paralysis. — Authors 
have  already  recognised  the  fact  that  locomotor  ataxy 
may  be  altered  in  its  course  by  the  onset  of  brain 
symptoms,  and  an  interesting  pamphlet  was  recently 
written  by  Dr.  A.  Pierret,  who  traced  the  relationship 
between  the  symptoms  of  locomotor  ataxy  and  the 
intellectual  disturbance  which  affected  the  patients. 
During  the  past  year  I  have  had  several  opportunities 
of  verifying  these  observations,  and  at  Guy's  and  St. 
Thomas's  I  have  seen  cases  which  I  am  kindly  allowed 
to  quote  for  the  purposes  of  this  work,  and  which  are 
good  examples:  W.  H.  J.,  set.  38,  compositor;  no 
history  of  neurosis  in  the  family,  no  excesses,  nor 
over- work  ;  married,  with  several  children.  Three 
years  before  admission  (June  23rd,  1881)  he  noticed 
difficulty  in  walking,  some  pain  in  the  feet,  which  in- 
creased. Two  years  before  admission  he  lost  all  sexual 
desire  and  power;  his  memory  was  noticed  to  be 
failing,  and  a  year  after  he  lost  himself,  as  he  de- 
scribed it,  for  an  hour  or  so.  At  another  time  he 
thought  his  wife  was  against  him,  and  on  awakening 
in  the  morning  he  could  not  remember  the  number 
of  his  children,  nor  how  old  he  was ;  he  became  dull 
and  moping,  solitary  in  his  habits,  with  alternate  fits 
of  excitement  and  depression  ;  he  was  also  disturbed 
emotionally,  and  had  to  give  up  his  work  in  conse- 
quence of  his  mental  weakness.  For  a  time  he 
recovered,    and   was    able    to    work    again,    but   two 


358     Insanity  and  Allied  Neuroses.  [Chap.  xiii 

months  before  admission  into  St.  Thomas's  he  had 
a  fit  lasting  from  five  to  ten  minutes,  entirely  losing 
consciousness ;  the  arms,  but  not  the  legs,  were  con- 
vulsed. From  this  time  the  difiicultj  in  walking 
became  much  worse,  patella  and  plantar  reflexes  ab- 
sent, gait  markedly  ataxic,  the  left  leg  being  the  more 
affected;  viscera  and  urine  normal.  On  July  1st  the 
patient  thought  he  was  dead;  was  depressed  and  con- 
fused in  his  mind  for  several  days  ;  two  small  ulcers 
appeared  on  the  sole  of  the  foot  ;  left  pupil  slightly 
the  larger,  neither  acted  to  light,  but  both  to  accommo- 
dation ;  nothing  abnormal  in  fundus  occuli  ;  some  loss 
of  sensation  over  arms,  trunk,  and  legs,  impressions 
being  delayed.  Towards  the  end  of  July  the  patient 
had  a  rigor,  with  a  temperature  of  103-8°  ;  but  this 
did  not  seem  to  affect  his  general  condition  in  any 
way.  In  August  he  was  reported  as  being  better 
mentally,  and  soon  after  he  was  discharged  from  the 
hospital.  Dr.  Bristowe  looking  upon  the  case  as  one  of 
locomotor  ataxy  with  mental  disturbance,  and  not  as 
a  case  of  general  paralysis ;  and  I  must  say  that,  from 
what  I  heard,  this  was  borne  out,  although  the  history, 
is  suspiciously  like  many  cases  of  general  paralysis. 

In  the  next  case  the  symptoms  were  somewhat 
different,  the  patient  being  younger,  and  the  mental 
excitement  more  acute.  William  R,,  set.  28,  an  en- 
gine-fitter ;  admitted  into  Guy's  under  Dr.  Mahomed, 
June  7th,  1883  ;  enjoyed  good  health  up  to  the  time 
the  present  symptoms  appeared.  For  several  years 
he  had  had  trouble  with  his  water,  first  incontinence 
and  then  retention.  Five  years  ago  loss  of  sensibility 
in  lower  extremities,  with  inco-ordination ;  three  years 
ago  severe  abdominal  pain,  with  vomiting ;  the  last 
two  years  has  lost  sensibility  in  hands  and  arms.  His 
symptoms  on  admission  were  those  of  typical  ataxy, 
no  symptoms  being  absent;  lightning  pains  in  the 
extremities,  and  gastric  crises  being  well  marked.    He 


Chap.  XIII.]  Locomotor  Ataxy.  359 

was  described  as  an  intelligent  man,  with  no  dulling 
of  intellect  in  any  way.  On  July  1st  he  suddenly 
became  unconscious ;  his  pulse  remained  good,  but  his 
respirations  became  infrequent ;  after  half  an  hour 
he  recovered.  During  the  next  fortnight  he  had 
several  similar  attacks,  in  one  of  which  unconscious- 
ness lasted  for  twelve  hours,  and  temperature  rose  to 
107°,  and  he  was  thought  to  be  dying.  On  the  6th 
of  July  he  became  noisy  and  threatening  ;  for  two 
nights  he  was  constantly  struggling  and  shouting  in- 
coherently ;  he  fancied  he  was  going  to  be  murdered, 
and  that  people  were  sticking  red-hot  wires  into  his 
legs.  He  became  more  quiet,  but  was  suspicious, 
thinking  he  was  going  to  be  poisoned,  and  refused 
food  ;  he  thought  a  policeman  was  walking  outside 
his  room,  and  he  appealed  to  him  for  protection ;  he 
thought  that  during  the  night  he  had  been  ripped  up. 
By  July  19th  he  had  recovered  so  far  as  to  admit  that 
he  had  had  delusions  and  hallucinations.  From  this 
time  he  improved  to  such  an  extent  that  he  was  dis- 
charged mentally  well,  although  ataxic. 

In  a  third  case,  W.,  set.  45,  admitted  into  Bethlem 
in  1879,  having  suffered  from  well-marked  loco- 
motor ataxy  for  some  years,  but  without  any  signs 
of  general  paralysis  of  the  insane.  This  patient  was 
again  seen  by  me  early  in  1884,  when  there  was  still 
no  evidence  of  general  paralysis.  He  was  quite  unable 
to  stand,  and  full  of  fear  of  persecution.  He  said  his 
legs  were  made  to  be  lightning  conductors,  and  his 
enemies  twisted  his  guts,  removed  his  semen  for  their 
own  purposes,  and  introduced  cats  up  his  rectum,  thus 
causing  his  loss  of  control  over  the  rectum. 

The  chief  symptoms  that  have  been  described  as 
occurring  with  locomotor  ataxy  are  those  of  suspicion, 
and  it  is  interesting  to  be  able  to  trace  a  direct  connec- 
tion between  the  morbid  sensations  of  a  patient  suffer- 
ing from  ataxy  with  delusions.     In  the  earlier  stages 


360     Insanity  and  Allied  Neuroses.   [Chap  xiv. 

of  this  patient's  case  there  had  been  gastric  crises  and 
lightning  pains,  and  it  is  not  a  very  extraordinary 
development  for  a  patient  to  misconstrue  these  feelings 
into  torture  by  poison  or  by  red-hot  Avires  introduced 
into  the  limbs.  The  whole  feeling  of  persecution  has 
to  be  studied  together,  and  it  will  be  found,  when 
cases  are  completely  investigated,  that  an  idea  of  per- 
secution, or  a  feeling  of  nervous  dread  connected 
with  nervous  weakness,  may  be  interpreted  by  ideas 
of  following,  haunting,  persecution,  detectives,  or  the 
like  by  insane  persons. 


CHAPTER  XIY. 

PUERPERAL    INSANITY. 

Insanity  associated  with  marriage — Insanity  associated  with  preg- 
nancy— Insanity  associated  with  delivery — Insanity  associated 
with  the  puerperal  state — Insanity  associated  with  lactation 
and  weaning. 

Before  considering  the  subject  which  more  especially 
belongs  to  this  chapter,  I  shall  refer  to  a  group  of  cases 
which  are  not  only  of  grave  medical,  but  also  of  legal 
importance.  There  are  cases  in  which  insanity  is  first 
recognised  soon  after  marriage.  These  must  be  consi- 
dered from  two  or  three  different  points  of  view.  First, 
there  are  those  in  whom  insanity  existed  but  was  not 
recognised  till  after  the  marriage  ;  secondly,  those  in 
Avhom  strong  predisposition  to  insanity  existed,  and 
the  attack  was  only  related  to  marriage  as  being  its 
exciting  cause  (other  subdivisions  might  here  be  made 
as  to  whether  the  excitement  was  moral  or  physical) ; 
and  in  the  third  group,  physical  exhaustion,  due  to 
great  excess,  caused  a  mental  break-down.  I  have 
seen  both  men  and  women  suffer  thus,  but  women 
suffer  more  often  than  men  from  shock,  distress,  and 
the  like,  while  men  suffer  more  from  exhaustion. 


Chap.  XIV.]       Insanity  and  Marriage.  361 

In  the  first  group,  cases  occur  which  are  of  the 
utmost  medico-legal  interest,  and  it  is  now  established 
that  nullity  of  marriage  can  be  declared  if  it  be  found 
that  one  of  the  contracting  parties  was  insane  at  the 
time  of  the  marriage  and  unable  to  understand  the 
nature  of  the  contract.  I  have  elsewhere  incidentally 
referred  to  the  case  of  Hunter  v.  Hunter,  in  which 
this  was  decided  ;  but  quite  recently  I  was  called  in 
to  see  another  case  with  the  following  history  :  A  girl, 
whose  father  was  and  is  insane,  became  engaged  to 
be  married  to  a  very  suitable  man.  Everything  ap- 
peared to  go  on  satisfactorily  till  the  wedding  day 
was  fixed,  when  the  girl  began  to  doubt  her  affection 
for  her  sweetheart.  She  ceased  to  superintend  her 
trousseau,  and  gave  up  many  of  her  favourite 
pursuits.  Her  friends  and  relations  thought  that 
as  soon  as  she  got  married  all  would  be  right ;  but 
when  married  she  seemed  still  more  desponding  and 
unlike  herself,  and  refused  altogether  to  allow  her  hus- 
band to  have  connection  with  her.  I  have  little  doubt 
but  that  with  time  she  may  become  herself  again,  but 
I  should  strongly  advise  her  husband  to  have  nothing 
more  to  do  with  her. 

A  Scotch  doctor  for  some  years,  after  a  very  suc- 
cessful academical  career,  went  into  general  practice 
and  bid  fair  to  succeed  in  his  profession.  He  be- 
came engaged  to  be  married,  and  nothing  in  any 
way  peculiar  was  noticed  in  his  manner  till  shortly 
before  his  marriage,  when  he  was  noticed  by  his 
friends  to  be  eccentric ;  but  this  was  at  the  time 
looked  upon  as  the  result  of  excitement,  and  likely  to 
prove  of  a  transient  nature.  On  the  day  of  the 
wedding  his  behaviour  was  still  more  strange,  and  his 
bride  was  alarmed  at  his  conduct.  This  state  of 
excitement  and  mental  instability  persisted,  so  at  the 
end  of  a  few  weeks  a  separation  had  to  take  place, 
and  soon  after  the  husband  was  sent  to  an  asylum, 


362      Insanity  and  Allied  Neuroses,  [chap.  xiv. 

where  his  symptoms  became  those  of  acute  mania, 
which  passed  into  a  condition  of  chronic  delusional 
insanity,  from  which  he  suffered  for  years ;  however, 
at  the  end  of  seven  years  a  change  took  place  in  his 
mental  state,  and  it  seems  now  doubtful  whether  he 
may  not  in  the  end  become  well  enough  once  more  to 
be  at  large.  I  am,  however,  convinced  that  his  wife 
would  be  perfectly  justified  in  sueing  for  a  divorce,  on 
the  plea  of  insanity  at  the  time  of  the  marriage. 

In  the  next  case  there  was  no  insanity  till  after 
marriage,  and  excess  is  said  to  have  started  the  break- 
down. T.  L.,  married,  set.  23,  actor  by  profession ; 
strong  nervous  tendency  in  the  family,  but  no  re- 
cognised insanity ;  no  previous  attack  of  insanity. 
He  had  been  married  three  days  before  the  attack 
broke  out.  It  began  with  great  taciturnity,  varied  by 
excitement  coming  on  without  assignable  cause.  He 
had  some  exaltation  of  ideas,  and  at  the  same  time 
fancied  he  had  committed  the  unpardonable  sin.  For 
eight  months  he  was  under  treatment  and  was  finally 
discharged  well,  and  has  remained  so  since.  I  have 
met  with  no  good  example  of  insanity  purely  started 
by  marriage,  both  as  a  predisposing  and  exciting  cause. 
In  most  of  the  cases  I  have  seen,  the  marriage  has 
been  the  exciting  cause  of  the  outbreak,  or  has  simply 
made  manifest  the  insanity  which  has  existed  before. 

Insanity  following  marriage  shock. — Emma  A., 
married,  set.  24  ;  epilepsy  in  family,  sober,  industrious, 
had  a  fit  of  some  kind  three  days  before  admission.  Her 
lover  attempted  her  seduction,  and  this  was  a  great 
grief  to  her,  and  caused  a  temporary  mental  distur- 
bance, but  she  went  on  with  the  engagement,  and 
was  married.  The  morning  after  marriage  she  was 
incoherent  and  wild.  She  wandered  from  home,  and 
was  taken  up  by  the  police.  She  threatened  suicide, 
and  she  took  a  violent  hatred  to  her  husband.  She 
had  hallucinations  of  hearing,  hearing  her  husband's 


Chap.  XIV.]        Insanity  of  Pregnancy.  363 

voice  chiefly  iii  the  right  ear.  She  was  nervous  and 
weak,  obstinate  at  times,  and  at  others  impulsive. 
She  remained  in  this  state  of  partial  weak-mindedness 
for  the  three  months  she  was  in  Bethlem.  I  heard 
she  slowly  recovered  after  some  months  at  home. 

Insanity  of  pregnancy  and  cMld-hirth. — A  very 
large  proportion  of  acute  cases  of  insanity  depend 
for  their  cause  on  the  above  conditions.  The  non- 
medical world  is  perfectly  familiar  with  these  cases. 
There  are  very  many  and  important  considerations  to 
be  referred  to  in  this  connection,  as  the  disorder  has 
more  social  aspects  than  have  many  other  forms  of 
insanity.  I  shall  have  to  consider  the  relationship 
of  the  woman  to  her  home,  her  husband,  and  her 
child. 

There  is  also  the  important  question  of  the  taint 
and  its  transmission  to  the  offspring,  and  the  liability 
to  recurrence  of  similar  attacks. 

The  question  of  recurrence  is  one  which  is  also  of 
great  importance  ;  and  I  am  inclined  to  believe  that 
the  discredit  which  attaches  to  "cures"  of  insanity, 
to  a  great  extent,  is  due  to  the  fact  that  so  many 
patients,  who  have  suffered  from  puerperal  insanity, 
have  other  attacks  under  similar  circumstances. 

The  subject  divides  itself  naturally  into  one  of 
three  periods,  namely,  the  insanity  of  pregnancy,  the 
insanity  of  delivery  (which  again  must  be  considered 
as  insanity  commencing  with  delivery,  that  imme- 
diately following  delivery,  and  insanity  coming  on 
a  few  weeks  later),  and  the  insanity  of  lactation,  or,  I 
would  prefer  to  say,  the  insanity  occurring  during 
lactation  or  at  the  period  of  weaning. 

I  would  premise  by  saying  that,  as  far  as  the 
symptoms  are  concerned,  there  is  absolutely  nothing 
characteristic  in  the  form  which  the  insanity  assumes  ; 
and  that  with  puerperal  conditions  you  may  have 
mania,  melancholia,  or  dementia  j  and  the  very  term 


364      Insanity  and  Allied  N'euroses.  [Chap.  xiv. 

puerperal  mania  is  misleading.  I  am  of  oj)inion  that 
inheritance  plays  a  very  important  part  in  puerperal 
insanity. 

First,  the  insanity  of  pregnancy.  These  cases  are 
not  nearly  so  common  as  those  following  childbirth. 
They  are  divisible  into  two  classes  :  those  in  which 
insanity  comes  on  in  the  earlier  months  of  pregnancy, 
and  those  in  which  the  derano-ement  occurs  durins^  the 
later  months.  It  must  be  remembered  that  it  is 
quite  common  to  get  exaggeration  of  the  ordinary 
reflex  nervous  symptoms  of  pregnancy  in  neurotic 
patients ;  that,  in  fact,  longings  of  pregnancy  may 
pass  beyond  the  limits  ordinarily  met  with  and  become 
insanity.  I  have  seen  cases  in  which  extraordinary 
appetites  have  been  connected  with  pregnancy  in 
neurotic  subjects  ;  and  what  is  more,  I  have  seen  the 
offspring  of  mothers  who  have  suffered  from  these 
unusual  conditions  themselves  later  develop  insanity. 
Insanity  of  pregnancy  may  occur  with  a  first  preg- 
nancy, or,  what  is  more  common,  it  may  occur  with 
a  later  one ;  and  I  am  inclined  to  believe  that  the 
following  is  the  more  common  mode  of  production 
of  such  cases  :  A  woman  of  insane  family  becomes 
pregnant,  and  with  the  pregnancy  has  some  marked 
nervous  peculiarities,  which  pass  off  and  are  forgotten 
till  after  delivery,  when  they  reappear ;  or  when 
sleeplessness,  irritability,  and  change  of  character 
usher  in  an  attack  of  ordinary  puerperal  insanity.  A 
second  and  third  pregnancy,  occurring  within  short 
intervals,  are  each  followed  by  attacks  of  insanity. 
But  with  the  fourth  and  fifth  pregnancy  the  eccen- 
tricity of  pregnancy  becomes  undoubtedly  an  insanity, 
and  the  patient,  during  the  earlier  months  of  preg-- 
nancy,  suffers  either  from  maniacal  or  melancholic 
symptoms,  which  may  pass  off  to  reappear  after 
pregnancy,  or  they  may  continue  steadily  through 
the    pregnancy  up   to   delivery,   and    beyond  it;    the 


Cbap.  XIV.]        Insanity  of  Pregnancy.  365 

patient  seeming  to  become  more  and  more  unstable  in 
consequence  of  preceding  attacks  of  insanity,  till  at 
last  a  very  much  less  force  is  required  to  upset  tlie 
balance.  One  such  case  I  have  known  to  become 
ultimately  so  little  able  to  resist  causes  of  depression, 
that  insanity,  at  first  following  delivery,  next  occurred 
with  pregnancy,  and  then  followed  a  simple  inflam- 
mation of  the  tonsils.  It  is  noteworthy  that  more 
disturbance,  both  of  body  and  mind,  may  occur  with 
male  than  with  female  pregnancies ;  and  cases  are 
recorded  in  which  chorea  or  epilepsy  has  followed 
only  when  the  children  have  proved  to  be  males  ; 
and  although  no  general  law  can  be  deduced,  yet  it 
is  interesting  to  find  that  popular  feeling  in  this  case 
coincides  with  medical  experience. 

Cases  are  also  recorded  in  which  insanity  has 
passed  ofi"  when  conception  has  taken  place  ;  and  I 
have  met  with  such  cases  as  the  following  :  A 
woman,  having  suffered  from  puerperal  insanity,  and 
having  been  secluded  for  some  months,  has  lost  all  her 
excitement,  but  has  become  apathetic,  and  might  be 
described  as  suffering  from  partial  dementia.  Nothing 
that  we  could  do  in  the  asylum  roused  her  or  made 
her  anxious  to  return  to  her  home  and  family ;  but 
by  sending  her  home  and  re-establishing  home  rela- 
lationship,  she  has  become  rapidly  better,  although 
sometimes  the  improvement  has  been  associated  with 
a  fresh  pregnancy.  I  do  not  think  the  pregnancy 
alone  was  the  cause  of  the  recovery. 

The  insanity  of  pregnancy  may  be  maniacal  or 
melancholic,  but  in  my  comparatively  small  expe- 
rience of  such  cases,  I  should  say  it  was  generally 
melancholic  with  hypochondriacal  symptoms,  or  with 
misinterpretation  of  the  ordinary  signs  of  pregnancy. 
Thus,  a  woman  suffering  from  insanity  of  pregnancy 
believed  that  the  vomiting  from  which  she  was  suffer- 
ing was    due    to    poison ;    acting  on   this   belief   she 


366      Insanity  and  Allied  Neuroses.  [Chap.  xiv. 

persistently  refused  food,  and  accused  her  husband  of 
wishing  to  get  rid  of  her.  If  I  see  a  case  in  which 
the  symptoms  of  insanity  have  slowly  developed 
during  the  first  two  or  three  months  of  pregnancy, 
and  have  been  directly  connected  with  excessive 
vomiting,  neuralgia,  and  sleeplessness,  I  generally  give 
a  favourable  prognosis,  considering  that  the  patient 
will  probably  re-establish  her  nervous  balance  by 
the  end  of  the  fourth  month ;  and  in  many  such 
cases  I  have  seen  the  patients  make  a  perfect 
recovery,  and  pass  through  the  puerperal  state  un- 
disturbed. Patients  of  this  class  may  break  down 
again  after  delivery,  or  they  may  have  similar 
attacks  with  succeeding  pregnancies.  But,  on  the 
other  hand,  I  have  known  cases  who  have  had 
no  second  attack  at  all.  As  to  treatment,  I  would 
advise  the  ordinary  measures  recommended  for  vomit- 
ing and  neuralgia  in  pregnancy ;  although  I  have 
failed  myself  to  do  good  with  such  drugs  as  cerium, 
hydrocyanic  acid,  or  morphia,  I  have  found  attention 
to  the  bowels  and  to  the  general  hygienic  measures  of 
much  greater  service. 

The  question  of  induction  of  premature  labour  has 
been  referred  to  me  by  several  obstetric  physicians, 
and  I  have  uniformly  said  that  I  have  never  yet  seen 
a  case  which  justified  its  practice,  for  in  the  first 
place  the  operation  will  probably  have  no  efiect  in  the 
way  of  cutting  short  an  attack  of  insanity,  and  adds 
somewhat  to  the  dangers  to  life  incurred  by  the 
patient.  I  have  seen  miscarriages  occur  in  the  insane 
without  any  mental  gain  following  them,  and,  there- 
fore, the  only  justification  to  my  mind  wmild  be  the 
destruction  of  a  child  who  ran  a  very  great  risk  of 
being  an  idiot. 

Insanity  coming  on  during  the  later  months  of 
pregnancy  is  more  common  than  that  last  described, 
and  is  generally  associated  with  melancholia.      Again, 


Chap.  XIV.]  Insanity  WITH  Early  Pregnancy.     367 

there  are  commonly  ideas  of  poison  in  the  food,  dis^ 
like  to  husband,  suspicions  and  general  dreads,  apathy 
and  negligence  of  personal  appearance  and  of  home 
duties.  Whether  only  a  coincidence  or  not,  I  cannot 
say,  but  I  have  recently  seen  general  paralysis  of  the 
insane  occurring  in  pregnant  women,  and  I  shall  have 
to  record  in  brief  one  or  two  such  cases. 

During  the  past  year  three  patients  have  been 
admitted  into  Bethlem  suffering  from  the  insanity  of 
the  later  months  of  pregnancy,  and  these  cases  have 
had  to  be  discharged  temporarily  to  be  delivered  at 
home,  as  no  provision  for  such  cases  exists  in  Bethlem. 

Example  of  insanity  with  j^Tegnancy.—Elizsiheth 
K.,  married,  set.  32,  has  had  three  children,  the  young- 
est being  sixteen  months  old.  She  was  admitted  into 
Bethlem  in  August,  1883,  she  then  being  five  months 
pregnant,  with  symptoms  of  insanity  which  had  lasted 
less  than  one  month.  They  came  on  suddenly  during 
one  night,  when  she  woke  up  and  said  that  she  had  cruci- 
fied Jesus  Christ.  She  attempted  to  destroy  her  life  by 
throwing  herself  from  the  window.  She  thought  her 
children  had  already  been  killed ;  had  hallucinations 
of  sight  and  hearing;  believed  there  were  faces  at  the 
window,  and  that  voices  were  audible  outside  her 
room  ;  she  was  in  constant  dread  of  some  terrible 
catastrophe  which  was  about  to  happen.  After  ad- 
mission she  was  noticed  to  be  dazed  and  confused, 
with  loss  of  memory.  This  condition  of  suspicion  and 
dread  passing  into  weak-mindedness  persisted  till  she 
was  sent  away  to  be  delivered.  Before  delivery  she 
appeared  to  regain  her  mental  soundness,  but  six 
weeks  later,  having  become  physically  weak,  she 
again  became  melancholic,  and  had  to  be  re-admitted 
into  Bethlem,  where  she  rapidly  recovered. 

Insanity  with  early  'preg7iancy.  Recovery  about 
five  months.  Delivery  and  maintenance  of  health. — 
Louisa  C,  set.  24 ;   no  insane  relations ;   second  attack 


368      Insanity  and  Allied  Neuroses.  [Chap.  xiv. 

of  insanity.  First  followed  child-birth.  Present 
attack  began  in  June,  1883.  (She  was  delivered  in 
March,  1884.)  She  became  restless  and  wanted  to 
leave  her  home.  She  was  emotional  and  quarrelsome; 
she  destroyed  her  clothes,  and  believed  her  husband 
was  very  rich.  On  admission  into  Bethlem  she  was 
noisy,  silly,  and  given  to  causing  mischief;  she  had 
ideas  that  her  child  had  been  poisoned.  She  became 
more  quiet  for  the  first  time  in  September,  but  again 
became  silly.  In  October  a  marked  improvement 
took  place,  which  continued  without  relapse.  She  was 
sent  out  on  leave,  was  delivered  naturally  of  a  healthy 
female  child,  and  was  discharged  recovered. 

In  the  following  case  we  have  a  very  good  example 
of  the  various  conditions  connected  with  puerperal 
insanity  and  the  insanity  of  pregnancy  :  F.  M,,  mar- 
ried, set.  21  ;  paternal  uncle  epileptic,  great  aunt 
insane,  one  brother  epileptic,  another  suffered  from 
insanity  produced  by  drink,  and  the  father  was 
an  extremely  excitable  man.  The  patient  had  suf- 
fered from  hysterical  attacks,  and  had  also  had  an 
attack  of  chorea  during  pregnancy.  She  had  a  pre- 
mature confinement  with  her  first  child,  but  did  not 
develop  insanity  then.  When  admitted  into  Bethlem 
she  was  pregnant  two  or  three  months.  She  was 
then  restless,  violent,  and  at  times  accused  herself  of 
unfaithfulness.  There  were  peculiar  choreic  move- 
ments of  her  limbs.  She  resisted  food  and  medicine, 
and  said  her  food  was  poisoned.  At  this  time  she 
had  the  morning  sickness  of  pregnancy.  For  some 
weeks  she  was  emotional,  violent,  and  destructive, 
refusing  her  food.  Later,  about  the  fourth  month  of 
her  pregnancy,  there  was  much  general  improvement. 
Her  aflfection  for  her  husband  returned,  and  she  began 
to  occupy  herself  in  her  ordinary  ways,  and  by  the 
fifth  month  of  pregnancy  was  well  enough  to  go  home 
on  leave,  and  later  was   delivered   of  a   female  child 


Chap.  XIV.]   Pregnancy  with  Paralysis.  369 

after  an  easy  labour.  Witliin  four  days  of  delivery 
she  became  noisy  and  violent  again ;  she  was  brought 
back  to  Bethlem,  where  she  went  through  another 
sharp  attack  of  acute  mania,  aud  had  to  be  fed  wdth  the 
stomach-pump  for  some  days.  Within  two  months  of 
her  delivery  she  was  again  convalescent,  and  was 
discharged  recovered,  and  she  has  had  several  children 
since  without  any  recurrence  of  insanity.  Fortunately 
domestic  and  other  conditions  were  favourable  for 
her. 

In  the  next  case  insanity  was  connected  with 
the  early  months  of  pregnancy.  Emma  N.,  set.  33, 
sister  likewise  insane;  first  attack,  following  domestic 
trouble.  It  came  on  two  months  after  she  had 
ceased  to  menstruate  from  pregnancy.  She  be- 
came strange  in  manner,  and  took  no  notice  of  her 
children  j  she  refused  food,  and  would  not  speak ; 
tried  to  strangle  herself  with  a  towel.  I  may  say 
that  this  pregnancy  followed  immediately  on  her 
recovery  from  her  last  delivery,  she  suckling  at  the 
time.  She  thought  men  were  waiting  for  her  in  the 
passage  to  take  her  away  ;  she  was  subject  to  halluci- 
nations of  hearing,  and  her  physical  condition  was  one 
of  extreme  weakness.  During  her  stay  in  Bethlem, 
I'est,  regular  diet,  and  quiet  caused  her  to  lose  her 
delusions,  and  she  has  been  discharged  sufiiciently 
recovered  to  pass  through  her  confinement  at  home. 

General  'paralysis  associated  with  'pregnancy. — 
That  with  general  paralysis  the  bodily  functions  may 
be  healthily  performed  in  many  respects  is  note- 
worthy. The  general  paralytic  may  appear  for  some 
time  strong,  stout,  and  lusty  ;  I  have  known  more  than 
one  general  paralytic  father  beget  children.  I  have 
now  to  note  cases  in  which  general  paralysis  occurred 
in  pregnancy.  In  one  case  the  patient  was  admitted 
into  Bethlem  pregnant,  with  fully  established  general 
paralysis.  She  was  delivered  of  a  living  child,  and 
Y— 14 


370       Insanity  and  Allied  NEUROSES.VZ\^z.^.y.\N. 

once  more,  while  at  home,  became  pregnant.  In  the 
other  case  the  symptoms  of  general  paralysis  occurred 
about  the  same  time.  Procreative  power  may  remain 
in  general  paralysis  till  quite  a  late  period  of  the 
disease,  and  so  may  pregnancy,  with  its  fearful  risk 
to  the  children. 

A.  B.,  married,  set.  33,  housewife,  mother  said 
to  have  died  of  "brain-softening;"  the  cause  of  the 
insanity  said  to  be  anxiety  and  over- work.  She  had 
had  two  children,  and  it  was  a  question  whether  her 
mental  condition  had  been  quite  the  same  during  the 
past  two  or  three  years.  When  admitted  into  Beth- 
lem  menstruation  had  been  absent  for  two  months, 
and  it  proved  that  she  was  pregnant.  She  was  rest- 
less, constantly  muttering  to  herself,  irritable,  talka- 
tive, and  incoherent;  muscularly  weak,  with  great 
tremor  of  facial  and  lingual  muscles;  speech  drawling 
and  indistinct,  with  general  hesitation ;  loss  of 
power  in  lower  extremities  and  bladder.  This  con- 
dition of  mental  and  physical  weakness  progressed 
till  she  was  discharged  to  be  delivered  elsewhere,  since 
which  time  the  mental  symptoms  have  been  less 
marked,  but  sufficiently  clear  to  verify  the  diagnosis. 

Temporary  relief  of  insanity  may  occur  during 
the  act  of  delivery.  Two  distinct  points  deserve 
consideration.  First,  the  insane  mother  may  be 
delivered  unconsciously,  there  being  anaesthesia,  so 
that  a  weak-minded  woman  may  give  birth  to  a  child, 
and  it  may  found  smothered  in  her  bed,  and  yet 
she  may  truthfully  say  she  did  not  know  of  its 
birth ;  secondly,  a  patient  who  has  suffered  from  in- 
sanity of  the  later  periods  of  pregnancy  may,  during 
labour,  appear  to  wake  up  and  to  appreciate  every- 
thing about  her,  only  to  relapse  after  delivery  is 
fully  accomplished. 

Insanity  of  delivery. — "With  delivery  one  has 
frequently  seen  considerable  mental  disturbance  as  a 


Chap.  XIV.]  Puerperal  Insanity.  371 

purely  natural  and  physiological  circumstance ;  but 
beyond  this  a  condition  may  arise  more  or  less  of 
temporary  derangement,  the  pain  of  labour  starting  a 
condition  of  mental  instability  which  may  become 
fully  developed  insanity  ;  and  just  as,  on  the  one  hand, 
I  referred  to  a  case  in  which  the  pain  of  labour  was  asso- 
ciated with  temporary  return  of  reason,  so  the  nervous 
shock  may,  on  the  other  hand,  upset  the  balance. 
Such  cases  are  rare,  and  have  notliing  special  in  them 
beyond  the  causation. 

Puerperal  insanity. — True  puerperal  insanity 
may  be  maniacal,  melancholic,  or  demen-^ed  in  form. 
As  I  have  said,  the  maniacal  attacks  are  those  which,  as 
a  rule,  come  on  soonest  after  a  delivery.  It  has  been 
said  that  there  are  critical  periods,  and  that  there  is 
special  danger  with  the  onset  of  milk,  with  the  recur- 
rence of  the  time  representing  the  menstrual  period, 
and  later,  that  weaning  is  a  source  of  special  danger ; 
but  I  have  failed  to  find  any  specially  critical 
periods. 

Before  considering  the  causation  of  puerperal  in- 
sanity more  fully,  I  would  call  attention  to  the  period 
of  delirious  excitement  which  may  come  on  during  the 
second  or  third  day  after  delivery.  A  mania  transi- 
toria  may  arise  suddenly  and  pass  off  as  quickly ;  the 
patient  will  have  a  flushed  appearance,  with  a  full 
pulse,  and  active,  talkative  delirium,  with  hallucina- 
tions, in  which  she  may  cause  damage  to  herself  and  to 
her  child.  This  state  of  excitement  may  be  frequently 
subdued  by  the  administration  of  a  purge  and  a  nar- 
cotic at  night.  Medico-legally  this  condition  is  of 
great  importance,  because  during  this  period  of  ex- 
citement the  mother  may  commit  infanticide,  and  not 
only  be  guiltless  as  far  as  responsibility  is  concerned, 
but  may  have  not  the  smallest  recollection  of  what  has 
taken  place. 

It  is  generally  accepted  that  physical  causes  plaj 


372      Insanity  and  Allied  Neuroses.  [Chap.  xiv. 

a  greater  part  in  the  production  of  this  variety  of  in- 
sanity than  do  moral  causes.  Inheritance  is  of  great 
importance  as  a  predisposition,  and  in  my  experience 
it  is  common  to  find  the  inheritance  directly  trans- 
mitted, that  is,  along  the  female  side.  I  have  known 
both  mother  and  daughter  suffer  from  puerperal  in- 
sanity. When  child-bearing  begins  late  in  age 
there  is  an  increased  danger.  Any  specially 
depressing  causes,  such  as  prolonged  suckling, 
followed  by  another  pregnancy,  or  rapidly  recurring 
pregnancies,  delivery  of  twins,  and  the  like,  are 
noteworthy  in  the  causation.  I  do  not  find,  in  my 
experience,  that  instrumental  labours  are  specially 
dangerous.  The  causes  in  most  cases  are  multiple, 
and  have  often  been  acting  some  time  before  delivery 
takes  place.  Thus,  during  pregnancy,  there  may  have 
been  a  drink-craving  which  has  been  yielded  to,  and 
this  has  predisposed  to  an  attack  of  insanity.  Other 
physical  causes,  such  as  ulceration  or  abscess  of  the 
breast,  may  have  had  a  share.  Insanity,  too,  may 
follow  eclampsia,  although  this  is  rare  also.  I  believe, 
however,  that  it  is  not  very  uncommon  to  meet 
with  violent-  acute  mania,  associated  with  pyeemic 
conditions,  and  a  few  patients  die  every  year 
in  Bethlem  in  whose  cases  I  believe  pysemia  has  had  a 
share  in  the  causation  of  the  disorder.  It  is  note- 
worthy that  labours  in  which  chloroform  has  been  ad- 
ministered have,  in  my  experience,  several  times  been 
followed  by  attacks  of  insanity  in  patients  who  have 
had  other  children  before  and  after,  born  without 
anaesthetics,  without  attacks  of  insanity. 

As  to  the  moral  causes,  grief,  worry,  anxiety,  and 
the  like,  are  the  most  effective.  Fewer  women  seem 
to  become  insane  after  the  birth  of  illegitimate  chil- 
dren than  might  have  been  expected.  Dr.  Clouston 
shows  that  in  Scotland  illegitimate  births  give 
rise   to   an    excessive   number   of   cases  of    insanity, 


Chap.  XIV.]  Puerperal  Mania.  373 

in  some  cases  seduction  and  the  birth  of  natural 
children  act  distinctly  as  a  cause.  Desertion  or  death 
of  husband,  and  loss  of  the  child,  may  act  as  severe 
causes  of  depression,  which  may  pass  beyond  a  natural 
limit.  The  above  are  the  more  common  causes,  vs^hich 
may  act  separately  or  combined.  The  ordinary  course 
of  an  attack  of  puerperal  mania  is  as  follows  :  A 
patient  having  had  no  bodily  trouble  to  excite  the  at- 
tention of  her  friends,  becomes  sleepless,  but  without 
depression  at  first ;  she  seems  ill  at  ease,  and  then 
may  complain  of  some  uneasiness  in  her  head ;  next 
she  complains  that  she  is  afraid  she  is  going  to  lose 
her  reason.  The  sleeplessness,  however,  is  the  most 
marked  early  symptom,  the  milk  and  lochia  often 
being  both  natural,  she  takes  a  dislike  to  her  husband 
and  perhaps  to  her  child,  making  trifling  complaints 
against  one  or  the  other.  She  often  complains  of  un- 
pleasant smells,  and  becomes  irritable  with  all  around 
her.  Next  she  complains  of  her  food,  and  may  alto- 
gether refuse  to  take  it.  This  period  of  sleeplessness, 
with  irritability  and  some  depression,  is  followed 
sooner  or  later  by  excitement,  chattering,  incoherent, 
blasphemous  or  amorous  talk,  and  then  the  attack  of 
mania  is  fully  developed.  There  is  nothing  special 
in  its  form,  but  there  are  a  few  symptoms  which  are 
more  commonly  present  than  perhaps  in  other  cases 
of  mania,  such  as  sleeplessness,  anxiety,  aversion  to 
relations,  erotic  tendencies,  mistakes  of  identity,  with 
hallucinations  of  smell  and  taste,  and  refusal  of  food. 
M.  B.,  married,  set.  28,  four  children,  no  insane 
inheritance,  the  last  confinement  three  weeks  before 
admission,  symptoms  coming  on  one  week  after 
delivery.  The  first  marked  symptoms  beyond  sleep- 
lessness were  peculiar  ideas  about  her  food,  antipathy 
to  those  dear  to  her,  violence  in  language,  destructive- 
ness  of  clothing,  dirtiness  in  habits,  and  blasphemous 
and  filthy  language.      She  had  hallucinations  of  sight 


374      Insanity  AND  Allied  Neuroses.iqm^v-^^^- 

and  hearing ;  said  she  saw  her  babies  in  heaven,  and 
that  she  was  bewitched  at  night ;  complained  of  nasty- 
smells  ;  thought  she  was  the  Virgin  Mary ;  and  was 
generally  obstinate  and  incoherent.  For  some  time 
she  remained  in  much  the  same  condition,  but  at  the 
end  of  five  months  she  was  sent  to  our  convalescent 
home,  and  at  the  termination  of  another  month  was 
discharged  well. 

The  next  case  was  in  many  respects  similar. 
Isabella  M.,  married,  set.  26,  no  insane  relations. 
This  was  her  second  child.  The  first  symptoms  followed 
between  the  second  and  third  week  after  delivery, 
when  she  became  sleepless  and  talkative ;  talka- 
tiveness is  a  very  common  adjunct  to  the  sleepless- 
ness. She  rapidly  became  worse,  her  language  grow- 
ing violent  and  obscene.  She  had  delusions,  and 
thought  she  was  the  mother  of  God  and  Mary  of 
Bethany ;  she  mistook  people  at  times  j  she  refused 
food  ;  she  called  her  husband  by  various  names,  at  one 
time  thinking  he  was  Christ ;  she  had  a  great  dislike 
to  her  child ;  and  she  was  fed  with  the  stomach- 
pump.  On  admission  she  was  suff'ering  from  a 
typical  attack  of  acute  mania,  and  this  condition  of 
excitement  continued  without  any  alleviation  for  five 
months,  when,  after  menstruation  had  been  re-estab- 
lished, she  recovered  completely  and  was  discharged 
well,  having  been  under  observation  six  months. 

There  are  some  special  points  in  these  cases 
requiring  consideration.  First,  as  to  the  milk.  Milk 
may  be  suppressed  at  the  time  of  the  outbreak ; 
it  may  continue  after  the  development  of  mental 
symptoms,  and  in  such  cases  there  is  great  danger  lest 
the  breasts  should  be  neglected  and  abscesses  form  in 
consequence  of  the  whole  of  the  attention  being  paid 
to  mental  symptoms.  In  Bethlem  friction  of  the 
breasts  with  salt  or  with  castor  oil  is  more  frequently 
adopted    than    the    use    of    belladonna,    and    with 


Chap.  XIV.]  Puerperal  Mania.  375 

satisfactory  results.  The  lochial  discharge  may  be 
suddenly  arrested  in  some  cases,  especially  in  those 
in  which  there  is  suspicion  of  pyaemia  \  but  in  an 
ordinary  case  of  puerperal  insanity  the  lochial  dis- 
charge continues  normally.  I  have  known  both  milk 
and  lochia  suppressed,  both  present,  or  one  present 
and  the  other  absent,  during  attacks  of  insanity. 
Puerperal  insanity  is  supposed  to  be  a  specially  curable 
disease,  but,  in  my  experience,  a  considerable  proportion 
of  the  cases  of  acute  mania  die,  bearing  out  what  I 
have  elsewhere  said,  that  mania  associated  with 
surgical  or  other  troubles  is  a  serious  bodily  disease. 
A  very  large  proportion  undoubtedly  do  recover^  and 
of  these  a  considerable  number  have  recurrences  of  the 
disorder ;  nor  does  it  follow  that  means  taken  to  pre- 
vent having  children  will  hinder  attacks  of  insanity. 
Besides  death  and  recovery,  I  have  to  record  that  a 
large  number  of  cases  remain  either  permanently  insane 
or  permanently  weak-minded  after  a  single  attack  of 
puerperal  insanity,  and  therefore,  even  in  a  first  attack, 
great  caution  must  be  used  in  giving  a  prognosis.  A  case 
of  acute  puerperal  mania,  having  lasted  from  two  or 
three  to  eight  or  nine  months,  will  often  become 
healthy  in  appearance  but  weak  in  mind.  Nourishing 
diet,  stimulants,  and  the  like,  have  produced  general 
health,  but  dementia  remains,  the  patient  taking  little 
or  no  interest  in  her  surroundings,  exj^ressing  no 
desire  to  return  home,  and  seeming  indifferent  to 
husband  and  children.  Such  cases,  as  a  rule,  will  be 
found  to  be  suffering  from  amenorrhoea,  or  if  not  the 
prognosis  is  grave  in  the  extreme.  I  always  look 
upon  the  consecutive  weak-mindedness  of  puerperal 
mania  as  being  curable  while  menstruation  is  absent, 
but  when  physical  health  is  re-established  without 
mental  gain  the  prognosis  is  bad. 

It  is   of  tJie  utmost  importance  that   such   cases 
should  be  sent  home  on  trial   before    all    chance  of 


37<3      Insanity  and  Allied  Neuroses.  [Ch^v-y^^"^- 

recovery  is  at  an  end.  I  believe  tliat  the  re- establish- 
ment of  home  relationships  is  about  the  best  means  of 
cure  for  many  of  these  cases.  As  far  as  the  treatment 
of  a  case  o£  acute  puerperal  mania  is  concerned,  I 
would  take  the  symptoms  somewhat  in  detail.  The 
general  and  guiding  principle  must  be  to  give  rest  and 
support.  Rest  must  be  procured  by  general  measures 
and  not  by  means  of  narcotics.  Chloral  and  bromide  of 
potassium,  morphia,  and  henbane  have  been  tried  and 
failed ;  they  rarely  secure  sleep,  and,  if  continued, 
leave  the  patient  more  unstable  and  farther  from 
health.  If  cases  like  these  are  treated  at  home,  it  will 
be  necessary  to  make  use  of  one.  or  other  narcotic, 
and  I  generally  advise  a  frequent  change  in  the 
remedies,  so  that  a  patient  is  treated  with  bromide 
of  potassium  one  night  and  chloral  the  next.  With 
sleeplessness,  beef-tea,  a  glass  of  spirits  and  water,  or 
a  bottle  of  porter  may  give  rest  when  narcotics  fail ; 
and  there  is  no  reason  for  any  dread  of  stimulants  in 
mania.  The  friends  and  certainly  the  children  should 
be  kept  out  of  sight  of  the  mother.  The  room  should 
be  kept  cool,  bright,  and  well  ventilated.  The  bowels 
should  be  kept  acting  regularly,  all  sources  of  local 
irritation  about  the  vagina  should  be  removed,  and, 
as  soon  as  the  patient  is  strong  enough,  bathing 
should  be  made  use  of.  When  strong  enough  to  get 
about,  the  patient  should  have  fresh  air,  out-of-door 
exercise,  and  a  change  to  the  seaside  is  often  bene- 
ficial. 

One  other  question  of  treatment  remains  as  to 
which  class  of  patients  should  be  sent  to  asylums,  and 
when.  There  is  a  very  strong  feeling  against  sending  a 
young  married  woman  to  an  asylum  when  the  attack 
follows  a  first  child,  the  feeling  being  natural  that  the 
child  or  children  will  sufier  socially,  and  that  the 
mother  herself  will  look  forward  with  dread  to  any 
future  confinement.     If  the  friends  have  ample  means, 


Chap.  XIV.]  Melancholia.  377 

if  their  home  is  in  a  healthy  district,  and  if  the  doctor 
can  see  the  patient  twice  daily  at  least  for  the  first  few 
weeks,  it  is  possible  to  treat  almost  the  most  serious 
case  at  home,  but  any  of  the  above  conditions  being 
wanting,  it  will  be  found  well  to  remove  the  patient 
from  her  former  surroundings.  The  chief  dangers 
arise  from  refusal  to  take  food,  exhaustion  from  un- 
trained attempts  to  keep  the  patient  quiet,  and  from 
wild  ungoverned  actions  depending  upon  delusions  in 
reference  to  husband  or  child  ;  so  that,  to  sum  up 
on  these  cases  of  puerperal  mania,  they  are  mainly 
curable,  but  some  die  and  others  remain  from  the 
first  weak-minded.  The  treatment  is  supporting  and 
calming,  the  smallest  quantity  of  narcotics  and  the  most 
food  possible ;  although  some  must  be  sent  to  asylums, 
they  must  not  be  kept  under  control  too  long,  but 
should  be  sent  home  as  soon  as  symptoms  of  danger 
have  passed ;  and  it  may  be  remembered,  that  although 
it  is  well  to  advise  caution  in  regard  to  other  pregnan- 
cies, it  does  not  follow  that  a  patient  will  keep  well 
in  consequence  of  having  no  more  children,  nor  does  it 
follow  that  because  she  has  had  one  attack  of  insanity 
she  will  have  attacks  following  the  birth  of  every  child. 

Besides  the  attacks  of  mania  there  may  be  attacks 
of  melancholia,  the  onset  of  the  disease  being  in  every 
respect  similar  to  the  attacks  of  mania  ;  sleeplessness, 
anxiety,  and  dread,  being  followed  by  delusions  in 
reference  to  husband  or  children,  and  associated  with 
hypochondriacal  or  other  similar  symptoms.  As  I 
said  before,  melancholic  symptoms  generally,  but  not 
always,  come  on  later  after  delivery  than  attacks  of 
mania,  and  in  the  cases  under  consideration  melan- 
cholia is  the  rule,  mania  the  exception. 

Harriet  K.  B.,  married,  aet.  26,  had  three  children, 
the  last  born  three  months  before  her  admission  into 
Bethlem.  Her  mother  suffered  from  insanity,  associated 
with  cancer.     The  first  symptom,  after  sleeplessness, 


378       Insanity  and  Allied  Neuroses.  [Chap.  xiv. 

was  refusal  to  take  food.  She  said  she  had  eaten  too 
much  food,  and  was  therefore  lost  j  that  God  would 
never  forgive  her,  and  that  there  was  no  passage 
through  her  bowels.  Her  habits  were  said  to  have 
completely  altered.  She  no  longer  took  interest  in 
her  children,  nor  would  she  go  out  of  the  house. 
These  symptoms  came  on  insidiously  without  any 
special  exciting  cause  within  a  fortnight  of  de- 
livery. She  was  suicidal,  and  represented  very  well 
the  type  which  may  become  dangerous  ;  for  patients  of 
this  class  will  not  only  desire  death  for  themselves, 
but  also  for  their  children.  Within  a  fortnight  of 
admission  this  patient  began  to  take  her  food  freely ; 
but  her  mental  symptoms  varied  so  that  she  would  eat 
well  for  a  time,  and  then  refuse  food ;  at  the  one  time 
being  less  influenced  by  her  false  ideas  than  at  the  other. 
She  became  more  actively  troublesome  about  five 
months  after  admission,  and  caused  anxiety  from  her 
rapid  emaciation.  It  was  found  she  was  in  the  habit 
of  eating  her  meals,  and  then  making  herself  sick. 
Being  carefully  watched,  this  was  prevented,  and  the 
patient  steadily  improved,  and  was  well  mentally  at  the 
end  of  six  months.  After  her  recovery  she  gave  an 
account  of  her  feelings,  of  which  the  following  are 
the  most  important  details  : 

May  3rd,  1884. 
Mrs.  K.  B. — Has  been  ill  since  birth  of  child 
(third),  18th  of  July  last.  From  that  period  until 
the  present  time  entire  cessation  of  courses.  About 
fourteen  days  after  confinement  felt  that  "  God 
would  not  forgive  her,"  "that  she  was  lost."  Ex- 
tremely depressed.  Thought  she  had  "  committed 
suicide  and  every  crime  under  the  sun."  Did  not 
hear  voices,  but  "  felt  that  something  told  her  to  go 
and  hang  herself."  She  procured  a  rope  for  that 
purpose,  but  was  prevented  from  carrying  out  her 
design    by     her  friends.      Was    extremely    sleeplesfi 


Chap.  XIV.]        Insanity  OF  Lactation.  379 

all  this  time.  Kefused  food,  thinking  she  would 
starve  herseJf^  but  yielded  when  pressure  was  used. 
She  had  great  repulsion  to  husband  and  children, 
which  she  says  was  a  great  change  in  her  sentiments, 
as  she  always  was  much  attached  to  both.  She  had 
no  desire  to  injure  the  child  last  born.  Gives  a 
perfectly  clear  and  lucid  account  of  her  condition, 
and  appears  to  have  an  active  remembrance  of  her 
delusions. 

In  some  cases  after  delivery  the  patient  slowly 
becomes  apathetic ;  she  takes  little  or  no  notice  of  her 
child,  and  may  be  slightly  emotional ;  her  indifference 
becomes  more  and  more  marked,  till  it  is  recognised  as 
a  mental  disorder.  She  neglects  her  personal  cleanli- 
ness, and  has  to  be  tended  like  a  child ;  this  condition 
may  slowly  pass  off,  or  it  may  be  but  the  early 
symptoms  of  an  incurable  state  of  dementia. 

InsRiiity  of  laictatioii. — Insanity  of  lactation 
is  a  variety  of  insanity  in  which  exhaustion  seems  to 
play  the  chief  part.  Some  women  suffer  severely 
from  weakness,  whenever  they  attempt  to  nurse 
their  children ;  but  the  cases  which  one  sees  in  an 
asylum  very  frequently  are  those  in  which  lactation 
has  been  prolonged  to  an  unhealthy  extent,  with  the 
idea  that  thereby  pregnancy  would  be  avoided. 
In  several  cases  I  have  seen  the  prolonged  lacta- 
tion produce  all  the  evils  of  weakness,  yet  succeeded 
by  a  pregnancy,  and  thus  not  only  has  there  been 
physical  depression,  but  moral  worry  in  addition. 
The  term  over-lactation  must  be  looked  upon  as 
purely  relative,  and  some  writers  would  look  upon  all 
cases  of  insanity  coming  on  two  or  three  months  after 
delivery  as  cases  of  insanity  of  lactation,  by  reason  of 
the  similarity  of  the  symptoms.  The  number  of  cases  in 
which  the  insanity  was  distinctly  traceable  to  lactation 
has  not  been  numerous  in  my  experience,  and  I  have 
seen  quite  as  many  cases  associated  with  pregnancy  as 


380       Insanity  and  Allied  Neuroses.  [Chap.  xiv. 

with  lactation.  The  symptoms  naturally  divide  them- 
selves into  the  bodily  and  mental.  There  is  commonly 
pallor,  with  a  peculiar  chlorotic  appearance,  giddiness, 
indigestion,  with  uneasy  feelings  at  the  top  of  the 
head,  shortness  of  breath,  and  complaints  of  palpita- 
tion, generally  associated  with  sleeplessness.  Mentally 
most  of  the  patients  are  depressed,  dreading  some  harm 
for  themselves  or  their  children,  irritable  at  times,  with 
delusions  of  unworthiness,  and  with  hallucinations  of 
sight,  smell,  and  hearing.  These  cases  frequently  get 
well.  I  expect  an  ordinary  case  of  this  kind  to  take 
from  three  to  six  months  in  an  asylum  to  recover,  and 
I  believe  the  sooner  you  are  able  to  send  such  cases  to 
the  seaside,  or  away  from  towns,  the  better.  Various 
forms  of  stimulant  and  tonic  should  be  given.  Iron  is 
very  useful,  and  partly  digested  foods  or  cod-liver  oil 
in  some  of  its  simpler  forms,  or  hydroleine,  will  be 
found  useful,  the  sleeplessness  being  treated  by  food 
rather  than  narcotics.  Such  attacks  may  recur,  and 
it  is  of  special  importance  to  get  the  general  health 
re-established  before  any  fresh  pregnancy  occurs.  The 
following  case  is  a  fair  example  of  the  ordinary  symp- 
toms met  with  in  this  disorder  : 

E.  M.,  married,  set.  29,  mother  and  two  bro- 
thers insane,  sister  died  of  phthisis.  The  patient 
has  had  rheumatic  fever ;  this  is  the  second  attack 
of  insanity ;  the  first  being  four  years  ago  j  she 
has  had  three  children,  the  youngest  being  four- 
teen months  old.  Since  the  birth  of  this  child 
she  has  not  menstruated ;  but  suckled  up  to  the 
time  of  her  insanity,  which  came  on  one  month  before 
admission,  when  she  became  very  excitable,  and  for  a 
time  was  maniacal,  having  a  tendency  to  be  erotic  ; 
she  had  hallucinations,  and  said  she  had  seen  the  devi], 
and  heard  cats  when  none  were  about.  She  mistook 
people,  and  was  coarse  and  violent  in  her  language. 
Within  two  months    of   admission  she  had  a  slight 


Chap.  XIV.]       Insanity  of  Lactation.  381 

attack  of  rheumatism,  followed  by  mental  improve- 
ment, and  from  this  time  her  general  health  became 
better,  and  she  recovered,  being  discharged  three 
months  after  admission. 

In  the  next  case  the  symjDtoms  were  those  of 
melancholia,  with  active  expression,  followed  by  re- 
covery. Florence  B.,  married,  set.  20  ;  maternal  ancle 
insane.  This  attack  followed  her  first  confinement, 
and  came  on  with  dulness  and  depression  four  months 
after  delivery.  She  became  steadily  more  dejected,  not 
speaking  nor  taking  any  interest  in  things  about  her. 
When  pressed  she  said  she  had  lost  her  soul,  and  that 
she  saw  strange  figures  in  her  room  \  that  she  had 
given  her  child  away,  and  that  her  husband  had  de- 
serted her.  She  feared  ruin,  and  was  concerned  about 
the  costliness  of  everything,  dreading  she  would  be 
unable  to  pay.  She  refused  her  food,  and  was  on 
several  occasions  noisy,  as  well  as  sleepless  at  night. 
She  tried  to  force  her  way  out  of  the  window,  and  had 
to  be  placed  on  the  ground  floor.  For  some  time  no 
change  took  place,  her  aspect  being  one  of  extreme 
misery,  and  her  face  covered  with  indolent  acne, 
which  she  pricked,  causing  her  face  to  be  sore  and  un- 
healthy-looking. Three  months  after  admission  her 
appetite  began  to  improve,  and  she  slept  better.  From 
this  time  her  interest  in  her  surroundings  re-developed, 
and  after  one  month's  leave  she  was  discharged,  re- 
covered, seven  months  after  admission,  and  eight 
months  after  the  beginning  of  the  attack. 

The  above  cases,  occurring  in  young  women,  are 
examples  of  the  curable  form ;  but  if  there  had  been 
several  previous  attacks  of  insanity,  and  if  the  jDatient 
had  been  older,  the  prospect  of  cure  would  have  been 
much  less,  such  patients  passing  into  states  of  chronic 
melancholia  or  of  weak-mindedness. 


382 


CHAPTER    XV. 

EPILEPSY    AND    INSANITY. 

Epilepsy  a  symptom  of  insanity — A  neurosis  allied  to  insanity 
by  origin  —  Similar  conditions  causing  both  insanity  and 
epilepsy — Epilepsy  producing  insanity — The  frequency  not 
the  severity  of  the  fits  of  most  importance  ;  the  younger 
the  patient  the  greater  the  danger  ;  idiocy  resulting— Bru- 
tality of  epileptics — Mania — Melancholia  or  dementia  as- 
sociated with  epilepsy — Ej)ileptic  furor. 

Epilepsy  and  insanity.— The  days  wlien  epilepsy 
was  considered  to  be  a  disease  apart  from  insanity  have 
passed  away.  Epilepsy  is  only  to  be  considered  as  a 
symptom  which  may  arise  from  an  almost  endless 
variety  of  changes  in  the  brain.  Vascular  or  structural 
changes  may  cause  a  condition  of  motor  instability  which 
is  represented  by  the  return  of  these  epileptic  discharges. 
We,  at  present,  do  not  know  what  starts  the  discharge  ; 
but  whatever  the  condition  is,  there  seems  to  be  a  uni- 
formity as  to  its  origin,  for  in  the  great  majority  of 
cases  the  symptoms  repeat  themselves  exactly ;  and 
in  referring  to  what  may  be  called  mental  epilepsy, 
the  chief  characteristic  will  be  found  to  be  the  abso- 
lute uniformity  of  the  symptoms ;  however,  we  are  not 
at  present  concerned  with  the  production  of  epilepsy, 
only  finding  space  here  for  the  record  of  mental  symp- 
toms which  may  be  distinctly  traced  to  the  epileptic 
conditions.  By  that,  I  mean  not  that  the  epileptic 
discharges  produce  all  the  mental  disturbance,  but 
that  the  conditions  which  give  rise  to  epilepsy  may 
also  give  rise  to  mental  as  well  as  motor  disturbance. 
In  some  cases  the  change  of  balance  or  change  of 
nutrition  which  is  represented  by  an  epileptic  fit  acts 
directly  in  producing  mental  disturbance.  First,  then, 
nearly  all  epilepsy  tends  naturally  to  weak-mindedness. 


Chap.  XV.]  Epilepsy.  383 

this  def)eiiding  rather  upon  the  frequency  of  the  fits 
than  upon  their  severity.  Epilepsy  is  extremely 
closely  allied  to  ordinary  insanity,  and  is  but  one 
branch  of  the  nervous  tree.  I  have  met  not  only  with 
members  of  the  same  family  suffering  from  epilepsy 
and  insanity,  but  I  have  seen  one  twin  sister 
insane  and  the  other  epileptic.  The  effect  of  the  fits 
depends  also  upon  the  age  at  which  they  commence ; 
many  cases  of  imbecility  and  idiocy  result  from  the 
onset  of  fits  in  childhood.  The  chances  of  mental  im- 
plication also  depend  upon  the  nervous  history  of  the 
family  and  also  upon  the  cause  of  the  disease,  cases  of 
so-called  idiopathic  epilepsy  being  more  hopeless  than 
those  cases  in  which  some  ascertainable  and  treatable 
cause  can  be  found.  It  is  only  necessary  to  say 
farther  of  these  cases,  that  suRple  petit  mal,  frequently 
recurring,  may  be  found  to  so  affect  a  young  man  or 
boy  that  he  is  no  longer  capable  of  being  educated  with 
persons  of  his  own  age  ;  he  becomes  solitary,  and  may 
damage  his  prospects  still  more  by  acquiring  habits  of 
self-abuse,  the  fits  continuing  and  probably  becoming 
more  frequent,  the  mind  also  suffering;  the  patient 
may  become  weak  and  silly,  living  an  organic  life, 
but  without  power  of  further  development  or  cure. 
The  above  is  one  of  the  simplest  cases. 

Not  uncommonly  epileptics,  with  general  intel- 
lectual degeneration,  either  develop  or  discover  low 
brutal  habits  and  tastes,  becoming  brutalised  in  aspect 
and  beastly  in  habits.  In  large  asylums  such  patients 
not  uncommonly  have  to  be  carefully  watched,  be- 
cause their  evil  tendencies  lead  them  to  commit 
u:nnatural  offences  or  brutal  bloodthirsty  acts.  The 
recurrence  of  fits  with  these  cases  may,  as  we  shall 
presently  see,  be  the  starting  point  for  fresh  excite- 
ment, or  they  may  tend  to  further  destruction  of 
mental  power  till  the  patient  is  left  a  helpless 
paralysed   dement.      In  some  cases  melancholia   and 


3^4      Insanity  and  Allied  Neuroses.  [Chap.  xv. 

hypochondriasis  are  connected  with  the  development  of 
epilepsy,  and  such  cases  may  be  suicidal  and  require 
the  utmost  supervision.  Patients,  whether  suffering 
from  ordinary  dementia,  maniacal  excitement  or  me- 
lancholia, may  live  for  considerable  j^eriods.  The  causes 
of  death  are  not  uncommonly  accidental,  and  many 
ingenious  contrivances  have  been  designed  to  prevent 
suffocation  in  the  fit,  but  now-a-days  the  Commissioners 
insist  upon  special  epileptic  wards,  with  low  beds,  and 
an  attendant  constantly  in  the  dormitory,  so  as  to  be 
able  to  attend  any  patient  in  fits.  Pillows  of  stretched 
perforated  material  have  also  been  suggested  as 
enabling  patients,  although  turned  on  the  face,  to  be 
able  to  breathe. 

The  next  consideration  is  the  relation  of  epilepsy 
to  certain  acutely  maniacal  outbursts.  It  is  common 
to  meet  with  cases  in  which,  immediately  before  or 
immediately  after  a  fit,  an  outburst  of  uncontrollable 
fury  of  the  most  destructive  kind  takes  place.  Such 
attacks  are  among  the  most  distressing  accidents  of  a 
large  county  asylum,  patients  suffering  in  this  manner 
being  completely  untrustworthy  and  excessively  dan- 
gerous. In  one  class  the  patients  become  querulous 
and  discontented,  asking  the  doctor  repeatedly  when 
they  are  to  be  discharged,  perhaps  also  attacking 
doctor  or  attendant,  and  then  stating  that  they  have 
done  it  to  get  out.  This  querulousness  may  be  but 
the  initial  symptom  of  an  outburst  of  epileptic  fits.  In 
these  cases  the  change  of  temperament  gives  some 
little  warning,  but  in  others  there  may  be  no  such 
indication.  In  the  more  common  cases  a  patient  falls 
down  in  an  epileptic  fit,  and  remains  unconscious  for 
a  longer  or  shorter  time,  the  unconsciousness  being 
often  followed  by  a  sudden  return  to  consciousness, 
marked  by  excessive  destructive  violence,  utter 
regardlessness  of  personal  danger,  and  an  extreme 
outburst  of  fury  which  can  only  be  recognised  when 


Chap.  XV.]  Masked  Epilepsy,  385 

it  lias  been  seen.  These  cases  are,  without  exception, 
the  most  dangerous  of  all  lunatics,  and  the  complete 
oblivion  which  surrounds  their  acts  of  violence 
renders  them  striking  examples  of  the  way  in  which, 
automatically,  acts  of  extreme  complexity  may  be 
performed  without  the  actor  having  the  faintest  recol- 
lection of  the  past. 

Masked  epilepsy  (I'epilepsie  larvee).— This 
condition  is  one  which  till  recent  years  was  not  recog- 
nised in  England,  and  even  now  it  is  not  uncommon 
to  meet  with  those  who  have  doubts  about  the  reality 
of  the  condition.  The  essentials  are  loss  of  recollec- 
tion of  whole  continuous  periods  in  life,  there  being 
what  may  be  called  a  double  consciousness,  and  it  is 
interesting  that  a  romantic  description  of  such  a  case 
should  form  the  basis  of  George  Sand's  "  Consaelo,"  the 
hero  of  this  story  being,  during  one  part  of  his  life,  com- 
pletely unconscious  of  what  he  has  done  in  the  other. 
The  condition  is  closely  allied  to  the  sleep-walking  state. 
That  this  condition  is  allied  to  epilepsy  has  been  shown 
by  French  authors  on  the  following  grounds  :  First,  it 
occurs  in  neurotic  subjects  ;  next,  it  may  be  associated 
with  epilepsy  in  one  way  or  another  ;  thirdly,  it  may  al- 
ternate with  epilepsy  and  take  its  place;  fourthly,  it 
may  end  in  ordinary  epilepsy ;  and  lastly,  it  may  be 
relieved  by  bromide  of  potassium.  The  details  of  these 
cases  are  only  to  be  fully  seen  in  Les  Annates  Medico- 
Psychologiques,  and  the  cases  there  recorded  are 
so  extraordinary  that  it  needs  a  very  considerable 
personal  knowledge  of  the  authors  to  allow  one  to 
accept  their  statements.  Patients  are  represented  as 
being  unconscious  for  days  together,  and  acting  in 
peculiar  but  highly  organised  waj^s.  Some  of  the 
simpler  cases  are  less  difficult  of  comprehension.  Thus, 
a  lady  of  culture  and  refinement  suddenly  and  with- 
out warning  turns  pale,  becomes  fixed  in  her  gaze 
and  begins  to  make  use  of  a  string  of  obscene  and 
z-U 


386     Insanity  and  Allied  Neuroses.     [Chap.  xv. 

blasphemous  phrases ;  at  the  end  of  a  few  minutes  she 
ceases,  flushes,  appears  confused,  and  in  no  way  remem- 
bers what  she  has  said  and  done.  Attacks  of  the  same 
description  recur  at  irregular  intervals,  always  asso- 
ciated with  pallor  and  the  use  of  similar  obscene  and 
blasphemous  language. 

In  other  cases  unconsciousness,  with  a  tendency 
to  run,  to  strike,  or  to  perform  some  simple  mechani- 
cal act,  occurs.  In  my  experience  I  have  only  met 
with  three  similar  cases ;  in  one  a  man  would,  from 
time  to  time,  lose  himself  and  wander  from  home  and 
find  himself  long  distances  from  where  he  started 
without  knowing  how  he  got  there  ;  and  in  another, 
a  man  with  strongly  insane  inheritance  caused  great 
distress  to  all  his  friends  from  time  to  time  just  as 
his  fortunes  appeared  to  be  mending.  Three  sepa- 
rate times  had  he  been  started  in  life  with  good  pros- 
pects, but  each  time  he  disappeared  without  rhyme  or 
reason,  to  be  discovered  in  some  part  of  the  continent 
in  a  state  of  poverty.  He  professed  unconsciousness 
of  what  had  taken  place,  and  I  believe  with  truth.  In 
his  case  he  also  suffered  later  from  an  attack  of  in- 
sanity. It  is  important  that,  if  this  condition  exist,  it 
should  be  fully  recognised,  but  it  would  be  a  very 
dangerous  thing  generally  to  allow  a  person  accused  of 
crime  to  plead  epileptic  unconsciousness.  The  question 
has  been  repeatedly  suggested  as  to  how  much  or  how 
complicated  the  acts  of  such  a  person  may  be.  For 
instance,  would  it  be  possible  for  a  person  suffering  in 
this  way  to  steal  only  valuable  things,  or  would  he,  if 
affected  by  a  desire  to  pilfer,  take  everything  that 
came  in  his  way  % 

One  case  recorded  in  French  literature  showed 
how  general  this  pilfering  might  be.  A  man  of 
education  and  position,  when  under  the  epileptic  influ- 
ence, would  collect  everything  that  came  in  his  way, 
and  the   result   showed   that  he  would  steal   things 


Ch  ap .  X  V.  ]  Ma  sked  Epil  EPS  V.  387 

altogether  undesignedly,  such  as  a  baby's  feeder  and  a 
cigarette  case,  things  useful  and  things  useless.  I 
should  therefore  hesitate  before  admitting  that  a 
patient  accused  of  stealing  valuable  things  did  this  as 
an  epileptic. 

Case  of  masked  e'pilepsy. — W.,  single,  aged  28, 
family  history  good,  intemperate )  as  a  result  of 
drink  and  injury  to  his  head  had  a  series  of  epileptic 
fits,  followed  by  melancholia,  in  consequence  of 
which  he  had  to  be  sent  to  the  county  asylum.  While 
there  he  was  depressed  and  tried  to  kill  himself.  At 
times  he  appeared  lost,  and  did  odd  things  ;  thus,  he 
would  whiten  the  fire-grate  and  blacklead  the  hearth. 

He  varied  a  great  deal,  but  towards  the  end  of  the 
fourth  year  he  recovered,  and  was  discharged  sane, 
but  still  subject  to  fits.  He  remained  well  over  a  year, 
but  after  his  discharge  he  was  subject  from  time  to 
time  to  fits,  which  were  preceded  by  an  aura,  which 
was  of  sufficient  duration  to  allow  him  to  undo  his 
necktie  and  collar.  These  fits  recurred  at  irregular 
intervals.  He  was  teetotal,  steady,  and  industrious. 
On  one  occasion,  while  he  was  walking  along  a  lonely 
road,  he  felt  a  fit  coming  on,  and  undid  his  necktie  and 
collar  ;  he  then  lost  consciousness.  On  recovery,  he 
found  himself  lying  by  the  roadside,  but  a  distance  of 
two  miles  from  where  he  remembered  undoing  his  neck- 
tie. Other  evidence  was  at  hand  to  show  that  he  had 
first  had  his  fit,  and  then  had,  in  a  state  allied  to  som- 
nambulism, got  up  and  walked  along  the  road  till  the 
post-epileptic  sleep  came  on,  when  he  lay  down  or 
fell  by  the  roadside,  and  slept  till  he  was  again  well. 

His  walk  was  said  to  have  been  staggering,  so 
that  those  who  met  him  passed  him,  believing  he  was 
drunk.  He  was  perfectly  unconscious  during  the 
walk  and  after  it.  Eits  have  recently  returned;  and 
he  has  had  once  more  to  be  sent  to  an  asylum. 

The  medico-legal  relationship  of  insanity  will  be 


388     Insanity  and  Allied  Neuroses.     [Chap.  xv. 

considered  later,  but  here  I  would  say  there  is  no 
doubt  that  a  very  close  connection  exists  between  the 
neuroses,  epilepsy,  and  criminality.  Epilepsy  is  not 
only  a  disease  commonly  feigned  in  jails,  but  is  also 
really  common  among  criminals. 

Treatment.— -\t  would  be  wrong  not  to  speak  of 
the  treatment  of  the  insane  suffering  from  epilepsy, 
though  their  cure  is  hopeless  at  present.  I  have 
pointed  out  that  in  county  asylums  they  are  specially 
placed  so  that  there  shall  be  the  minimum  of  risk  of 
their  becoming  asphyxiated  when  in  fits  ;  but  besides 
this,  many  other  precautions  must  be  taken.  They 
must  be  prevented  from  falling  into  fire  or  water,  and 
it  is  well  to  provide  them  with  head-gear,  resembling 
in  many  points  a  thick  turban,  so  that  if  they  fall  on 
their  heads  little  or  no  harm  results.  The  medical 
treatment  is  still  a  matter  for  grave  consideration,  one 
class  of  medical  men  looking  to  bromide  of  potassium 
as  a  sheet  anchor,  whereas  another  class  believes  that 
more  harm  is  done  by  bromide  than  if  the  patient  be 
left  untreated.  Some  think  that  iron  is  distinctly  in- 
jurious, and  others  look  upon  the  effect  of  mineral 
tonics  as  certainly  beneficial.  Many  of  the  superin- 
tendents of  county  asylums  think  that  purgatives  are 
the  desideratum.  My  opinion,  founded,  I  must  own, 
on  but  small  experience  of  these  cases,  is  that  general 
hygienic  treatment  is  the  most  useful,  and  that  in  some 
cases  bromide  of  potassium  prevents  the  frequent  re- 
currence of  fits,  and  thereby  does  great  service  j  that 
purges  are  useful,  especially  in  those  cases  in  which 
food  is  taken  in  large  quantities,  and  that  general 
treatment  is  to  be  looked  to  rather  than  special,  for  at 
present  it  appears  to  me  we  are  no  nearer  having  any 
one  specific  cure  for  all  the  many  conditions  which 
give  rise  to  epilepsy  than  we  were  in  the  days  when 
everything  from  a  snail's  shell  to  a  pumpkin-seed  was 
recommended. 


Chap.  XVI.]    Insanity  with  Brain  Tumour.         389 

In  one  case,  a  boy  with  early  epilepsy  and  tendency 
to  weak-mindedness  was  sent  away  from  the  city  in 
which  he  lived,  and  was  prevented  from  following  his 
precocious  tastes  for  reading  and  music.  He  led  the 
life  of  a  little  savage  for  a  few  years,  and  at  thirteen 
or  fourteen  was  a  healthy  animal,  without  fits,  and 
without  education ;  at  sixteen  he  was  quite  up  to  the 
average  schoolboy,  and  has  kept  well. 

Education,  if  not  pressed  unduly,  may  be  pursued 
with  many  epileptic  children  without  injury. 


CHAPTER  XYI. 

BRAIN    TUMOURS.        MULTIPLE    SCLEROSIS. 

Insanity  with  brain  tumour — Insanity  with  multiple  sclerosis. 

Insanity  with  brain  tumour* — Any  intracranial 
growth  may  cause  mental  disorder,  and  the  chief  in- 
terest at  present  of  these  local  changes  is  in  the 
observance  of  the  clinical  symptoms  which  are  gradu- 
ally enabling  the  physiologist  to  localise  function, 
and  thus  aid  the  philosopher  in  his  divisions  of 
mind.  It  is  rare  to  meet  with  insanity  directly  de- 
pending upon  a  growth  within  the  skull.  Tumours 
may  arise  in  connection  with  the  blood-vessels,  with 
the  membranes,  with  the  bones,  or  with  the  brain 
itself.  These  growths  may  chiefly  affect  the  cerebrum 
or  cerebellum ;  the  growths  may  be  malignant  or 
simple,  the  most  common  being  sarcomatous,  tuber- 
cular, and  syphilitic.  The  chief  and  most  general 
mental  symptom  connected  with  all  these  growths 
is  increasing  stupidity ;  convulsions  may  be  present, 
with  some  local  paralysis.  Among  several  thousand 
patients  in  Bethlem,  I   have  only  met,  jjost  mortem^ 


390     Insanity  and  Allied  Neuroses.    [Chap.xvi. 

with  one  abscess  and  one  exostosis  apart  from  un- 
doubted syphilitic  tumours.  The  abscess  occurred  in 
a  woman,  who,  having  had  previous  attacks  of  melan- 
cholia, and  who  had  a  sister  also  melancholy,  was 
admitted  to  Bethlem  acutely  maniacal ;  the  patient 
passed  into  a  condition  of  restless  excitement,  with 
refusal  to  take  food,  and  in  the  end  died.  On  post- 
mortem examination  a  considerable  abscess  with  thick 
walls  was  found  spreading  from  the  membranes  into 
the  brain. 

The  changes  connected  with  syphilitic  tumours  are 
considered  elsewhere,  and  the  other  tumours  producing 
epileptic  convulsions  naturally  fall  under  the  head  of 
epileptic  insanity. 

Insanity  \iritli  multiple  sclerosis. — It  has 
surprised  me  that  so  few  cases  have  been  recorded  of 
insanity  with  the  above  disease,  the  only  other  case  I 
know  of,  besides  the  one  I  am  about  to  record,  being 
that  recorded  in  the  April  number  of  the  "  Journal  of 
Mental  Science,"  1884,  published  by  Dr.  Gasquet,  in 
which  considerable  excitement,  and  symptoms  like 
those  of  general  paralysis  of  the  insane,  were  present, 
but  with  a  feeling  of  physical  weakness.  The  case  I 
record  was  transferred  from  St.  Thomas's  Hospital,  a,s 
being  altogether  unmanageable  among  ordinary  hospital 
patients. 

Ernest  D.,  single,  set.  21,  sculptor,  paternal 
grandmother  insane,  uncle  dipsomaniac,  phthisis 
on  maternal  side ;  first  attack  of  insanity^  no  cause 
known  ;  the  patient  was  admitted  in  October,  1878, 
having  been  excitable  and  irritable  for  five  weeks.  It 
was  said  that  he  had  choreic  movements  gradually 
coming  on  for  two  years,  during  which  time  he  was 
a  patient  at  the  Queen  Square  Hospital.  When 
admitted  into  St.  Thomas's  Hospital  the  case  was  con- 
sidered to  be  that  of  typical  sclerosis,  having  all  the 
peculiarity   of   head    and    limb   movement    which    is 


Chap  XVI.]  Insanity  with  Multiple  Sclerosis.    391 

common  to  that  disease.  Soon  after  admission  the 
excitement  and  irritability  became  more  marked, 
and  frequently  he  was  either  childish  or  luicontrol- 
able  ;  he  screamed  and  shouted,  and  was  violent  to 
himself  and  others.  On  admission  into  Bethlem  he 
is  described  as  fairly  nourished,  of  middle  height,  un- 
able to  stand;  any  attempt  at  movement  was  followed 
by  irregular  spasmodic  movement  of  all  his  limbs; 
he  generally  lies  with  his  head  drawn  forward  from  his 
chest  with  a  peculiar  jerking  backward  and  forward  ; 
no  nystagmus ;  speech  scanning  and  all  but  unintel- 
ligible ;  evacuations  and  urine  passed  under  him.  He 
was  detained  in  Bethlem  till  the  end  of  January,  when 
he  was  discharged  weak-minded  and  paralysed,  but 
with  no  further  tendency  to  mental  excitement.  In 
the  end  he  died  in  Wandsworth  asylum  from  the 
extension  of  the  sclerosis. 

I  have  no  doubt  that  a  few  years  ago  this  case 
would  have  been  looked  upon  as  one  of  chorea  with 
mental  symptoms ;  and  it  was  in  many  particulars 
like  that  disease,  but  there  was  sufficient  evidence  to 
make  the  diagnosis  sure. 

There  are  other  convulsive  conditions  which  de- 
serve a  passing  notice  in  relationship  to  mental  changes. 
With  chorea,  I  should  say,  it  is  common  to  meet  with 
some  intellectual  weakness ;  and  if  the  cases  are  ex- 
tremely severe  this  may  pass  into  absolute  dementia, 
while  in  fatal  cases  delirium  and  great  excitement  may 
be  present.  Dr.  Gowers  has  collected  evidences  of 
the  relationship  between  chorea  and  other  forms  of 
nervous  disease  ;  and  in  Bethlem  it  is  common  to  find 
that  patients,  who  have  suffered  from  chorea  in  early 
youth,  have  in  later  years  become  subject  to  hysteria 
or  other  true  neuroses. 

Of  846  patients  admitted  into  Bethlem  only  six 
had  had  chorea,  and  of  these  four  were  maniacal,  one 
melancholic,  and  one  demented. 


392 


CHAPTER    XYII. 

SYPHILIS    AND    INSANITY. 

Moral  effects — Syphilopliobia — Softening  gummata — Epileptic 
fits — Arterial  disease — Weak-mindedness — General  jiaralysis — 
Cachectic  states. 

"When  treating  of  the  causation  of  insanity  generally, 
I  referred  to  some  of  the  relationships  which  syphilis 
holds  to  mental  unsoundness,  and  shall  here  in  more 
detail  give  the  results  of  my  experience. 

Syphilis  may  act  morally  or  physically.  It  may 
colour  the  melancholia  from  which  a  patient  is  suffer- 
ing, and  thus  cause  him  to  believe  that  he  is  a  source 
of  physical  as  well  as  of  moral  contagion. 

It  may  be  the  starting-point  of  syphilophobia, 
which  I  look  upon  as  a  form  of  hypochondriasis.  I 
have  never  met  with  insanity  depending  on  the  febrile 
disturbance  of  early  syphilis. 

Constitutional  syphilis  acts  by  causing  (1)  gum- 
mata ;  (2)  by  producing  disease  of  the  arteries  ;  (3)  by 
producing  local  degenerations ;  (4)  by  causing  a 
cachectic  condition. 

The  gummata  may  lead  to  epilepsy,  which  in  its 
turn  causes  weak-mindedness  ;  or  they  may  produce 
some  local  brain  change,  associated  with  special  dis- 
orders and  consequent  insanity ;  or  they  may  produce 
brain  changes  from  affection  of  the  motor  areas  of  the 
brain,  which  are  not  to  be  distinguished  from  general 
paralysis  of  the  insane. 

The  syphilitic  disease  of  the  arteries  may  give  rise 
to  apoplectic  seizures  or  to  simple  dementia. 

The  local   changes    are,  in    my    belief,    associated 


Chap.  XVII.] 


Optic  Neurosis. 


393 


either  with  locomotor  ataxy,  or  more  frequently  with 
progressive  paralysis,  associated  with  changes  in  the 
lateral  columns  of  the  cord. 

The  cachexia  of  constitutional  syphilis  may  give 
rise  to  various  shades  of  melancholia,  ending  in  some 
lung  disease  if  not  cured. 


A  case  of  Syphilitic  Dementia. 

The  next  point  of  interest  in  the  relationship  of 
syphilis  to  insanity  is  that  optic  neuritis  may  give  rise 
to  delusions.  Thus,  a  trainer  to  a  large  racing  stable, 
who  had  within  four  years  contracted  syphilis,  became 
anxious  on  account  of  his  impaired  vision,  and  was  ad- 
mitted into  one  of  the  London  hospitals,  where  his  sight 
became  more  obscure,  and  he  became  querulous  and  hard 
to  manage.     He  believed  persons  were  tampering  with 


394     Insanity  and  Allied  Neuroses.  [Chap.  xvii. 

his  goods,  and  were  going  to  do  him  some  harm.  He 
took  the  law  into  his  own  hands,  and  struck  those  near 
him ;  his  violence  and  delusions,  caused  him  to  be  sent 
to  Bethlem.  He  was  put  under  energetic  mercurial 
treatment,  and  rapidly  regained  his  sight  and  lost  his 
delusions,  and  he  has  remained  well  for  the  last  six 
years.  Here  we  have  a  good  example  of  the  develop- 
ment of  insanity  out  of  natural  causes.  The  patient 
by  training  and  occupation  was  very  suspicious,  and 
loss  of  sioht  made  him  more  so. 

The  last  special  point  I  wish  to  consider  briefly  is 
the  relationship  of  syphilis  to  general  paralysis  of  the 
insane. 

A  fair  number  of  cases  of  this  disease  have  sis^ns 
of  syphilis  upon  them,  and  more  have  histories  of  the 
malady.  I  am  not  prepared  to  say  that  there  is  a 
special  form  of  general  parah' sis  always  due  to  syphilis, 
but  I  have  met  now  with  about  a  dozen  cases  in  whom 
the  two  diseases  occurred  and  seemed  to  be  related. 

Some  of  the  cases  had  peculiarities  which  are,  at 
least,  noteworthy. 

Syphilitic  gumma-insanitij.  Recovery. — It  is  not 
necessary  to  give  in  detail  all  the  facts  which  have 
led  me  to  the  above  conclusions,  and  I  would  only 
refer  to  a  few  instances  as  examples.  One  man, 
who  had  had  syphilis  five  years  before,  was  ad- 
mitted sufiering  from  partial  dementia  with  ptosis, 
external  strabismus,  and  dilated  pupil.  No  treatment 
did  any  good,  and  for  months  he  steadily  lost  ground  ; 
so  weak  did  he  become  that  it  was  decided  to  allow 
him  to  remain  till  his  death,  and  all  medicine  was  dis- 
continued. He  began  to  take  his  food  better  and  gain 
flesh,  and  in  about  another  three  months  was  fit  for  a 
change,  and  in  the  end  was  discharged  well.  During 
the  next  four  years  he  had  fresh  outbreaks  of  syphilis, 
as  shown  by  shin  nodes,  ulcer  on  prepuce,  and  ulcer 
on  septum  nasi,    but    prolonged  mercurial  treatment 


Chap.  XVII.]  Syphilis  and  General  Paralysis.    395 

and  Turkish  baths  have  finally  fully  re-established  his 
health,  nothing  remaining  but  the  dilated  pupil. 

I  have  seen  several  similar  cases,  and  in  two  fatal 
results  have  followed.  In  one  no  coarse  brain  lesion 
of  any  kind  was  found  ;  and  in  a  second,  thickening  of 
the  membranes  in  the  course  of  the  sixth  explained 
the  internal  strabismus  which  was  present,  and  a  small 
gumma,  resting  on  the  optic  commissure,  explained  the 
optic  neuritis  and  loss  of  ^dsion. 

Syphilis  and  general  paralysis. — A  single  man,  of 
thirty,  who  had  syphilis  five  years  before,  began  to  do 
odd  things,  and  to  cause  his  friends  anxiety,  in  con- 
sequence of  his  mental  weakness,  and  foolish  and 
wasteful  actions.  He  was  restless,  emotional,  irritable, 
and  with  failmg  memory.  He  would  not  be  ruled  by 
his  friends,  and  had  to  be  sent  to  an  asylum.  Here 
he  was  silly  and  restless.  He  decorated  himself  with 
leaves  and  flowers.  He  was  in  fair  general  health, 
but  the  tremor  of  tongue  and  lips  was  very  marked  ; 
his  speech  was  hard  to  understand.  All  his  reflexes 
were  much  exaggerated  ;  there  was  no  paralysis  of 
any  cranial  nerve. 

He  remained  in  tliis  state  for  two  years,  then 
became  bed-ridden,  with  contraction  of  the  lower 
extremities ;  and  with  the  onset  of  fits  and  the  develop- 
ment of  bed-sores  he  died. 

There  was  wasting  of  ascending  frontal  with 
parietal  convolutions,  and  of  the  first  frontals  ;  excess 
of  fluid  ;  no  local  tumours  ;  marked  grey  degeneration 
of  the  lateral  columns  of  the  cord. 

Such  cases  are  young,  often  single  j  they  always 
liave  exaggerated  reflexes,  generally  with  capillary 
congestion,  similar  to  that  seen  in  cirrhosis  over  malar 
prominences. 

In  all  such  cases  anti-syphilitic  treatment  should 
be  tried,  but  will  fail  if  distiixct  symptoms  of  general 
paralysis  are  present. 


396 


CHAPTER   XYIII. 

RELATIONSHIPS     BETWEEN     INSANITY     AND     PHTHISIS 
PULMONALIS. 

Degenerative  lung  changes  are  common  terminations  of  nervous 
diseases. — Ptithisis  in  one  parent,  with,  neurosis  in  the  other 
makes  the  prospect  of  neurotic  inheritance  greater. — Phthisis 
in  the  insane  is  frequently  without  general  symptoms. — In 
the  insane  there  is  suspicion  and  refusal  of  food. — Degene- 
rative lung  changes  causing  death  occur  in  melancholia  and  in 
general  paralysis. — Phthisis  may  kill  patients  who  are  con- 
valescing from  an  acute  attack  of  mania  or  melancholiq, — 
Spasmodic  asthma,  with  insanity. 

Phthisis  and  insanity.  —  Whatever  in  the 
future  may  be  shown  to  be  the  relationship  between 
bacilli  and  phthisis,  I  am  sure  that  there  will  be 
proved  to  be  a  very  distinct  connection  between 
some  low  forms  of  lung  inflammation  with  destruc- 
tion of  tissue  and  death  and  disorder  of  the  nervous 
system.  It  has  been  sufficiently  long  recognised  that 
the  ordinary  termination  of  progressive  paralysis  is  by 
some  inflammation  of  the  lungs,  and,  in  my  opinion, 
this  is  not  altogether  due  to  mechanical  congestion. 
Later,  I  shall  point  out  various  relationships  which  I 
have  found  to  exist  between  phthisis  and  insanity  ; 
and  I  repeat  here  my  belief  that  phthisis  occurring  in 
one  parent,  and  neurosis  in  the  other,  will  make  the 
tendency  to  nervous  disorders  much  greater  than 
without  phthisical  parentage.  There  is  a  special  set 
of  symptoms  associated  with  phthisis  occurring  in 
insane  patients. 

One  of  the  peculiarities  of  phthisis  in  the  sane  has 
long  been  recognised  to  be  a  general  hopefulness,  so 
that  patients  who  are  rapidly  emaciating,  who  are 
coughing   and  spitting,  sweating    and    suffering  from 


Chap,  xvrii.]       Phthisis  and  Insanity.  397 

colliquative  diarrhoea,  will  tell  the  doctor  that,  if  they 
could  only  get  rid  of  their  cough,  they  would  be  well 
again.  On  the  other  hand,  in  an  asylum  phthisis  is 
found  associated  with  melancholic  symptoms,  with  few 
or  no  physical  symptoms  ;  but,  as  a  rule,  with  con- 
firmed suspicion  and  obstinacy.  The  general  course  of 
the  disease  and  the  symptoms  are  as  follows :  A 
patient,  with  insane  inheritance,  becomes  out  of  health, 
dyspeptic,  and  generally  ailing.  His  friends  suspect 
that  the  family  complaint,  phthisis,  is  developing ;  but 
the  signs  of  the  disease  are  so  few  that  it  is  thought  a 
change  of  scene  will  remove  the  trouble.  He  is  sent 
on  a  voyage,  and  for  a  time  his  general  health  im- 
proves ;  but  with  this  there  has  been  noticed  an 
irritability  of  temper  and  a  suspiciousness  which  were 
quite  unnatural  to  him.  In  some  cases  the  symptoms 
require  the  patient  to  be  placed  in  an  asylum  abroad ; 
and  it  is  not  till  he  has  been  under  observation  for 
some  time  that  the  true  state  of  matters  is  discovered. 
A  fresh  attack  of  irritability,  and  a  further  develop- 
ment of  emaciation,  lead  to  careful  exploration  of  the 
chest,  when  it  is  discovered  there  is  dulness  at  one  or 
both  apices.  At  the  same  time  refusal  to  take  food  is 
marked,  and  I  would  say,  in  the  main,  I  agree  with 
what  Dr.  Rayner  has  said,  that  the  refusal  to  take 
food  is  most  marked  with  the  earliest  symptoms  ;  that, 
in  fact,  with  consolidation  refusal  to  take  food  is  pretty 
constant,  and  that  breaking  down  of  lung  tissue  is 
frequently  associated  with  a  return  to  eating.  I  am 
in  the  habit  of  saying  that,  in  the  cases  of  phthisis, 
the  pneumogastric  itself  conveys  wrong  impressions, 
and  that  the  irritation  at  the  lung  end  is  treated  as  if 
it  were  derived  from  the  stomach.  At  any  rate,  with 
phthisis  obstinate  refusal  of  food  is  so  common  that 
when  I  am  investigating  a  young  case  of  insanity,  and 
hear  that  there  is  obstinate  refusal  of  food  and  pro- 
gressive wasting,  I  at  once  suspect  phthisis,  and  seek 


398     Insanity  and  Allied  Neuroses.  [Chap,  xviir. 

for  it.  There  may  be,  at  this  period,  nothing  in  the 
waj  of  cough  or  expectoration  to  excite  attention  ;  but 
there  is  occasionally  early  haemoptysis  j  and  in  my 
experience  this  is  common  late  in  the  disease,  and 
then  is  one  of  the  causes  of  death. 

Besides  refusal  of  food,  which  refusal  is  due,  in 
most  cases,  to  ideas  that  there  is  poison  or  filth  of 
some  description  put  into  the  food,  there  is  often 
obstinacy  of  an  extreme  kind  to  any  interference  from 
without ;  so  that  patients  will  resist  being  dressed  in 
the  morning,  and  will  equally  object  to  being  un- 
dressed at  night.  They  will  resist  being  moved,  and 
they  will  be  in  direct  opposition  to  all  about  them. 
Some  of  these  cases  have  a  considerable  flow  of  saliva, 
and  others  ai'e  constantly  ejecting  saliva  and  mucus 
from  their  mouths,  probably  because  they  believe  their 
secretions  to  be  poisoned.  Diarrhoea  comes  on,  and 
the  utter  neglect  of  personal  comfort  necessarily 
causes  great  trouble  to  friends  and  attendants.  Bed- 
sores rapidly  form.  Cases  of  this  kind  may  last  for 
many  months  without  any  apparent  change  in  their 
mental  state  ;  but  it  is  common  to  meet  with  phases 
of  mental  improvement  associated  with  exacerbations 
of  the  lung  trouble.  I  have  seen  one  case  always 
better  after  a  severe  hsemorrhage,  and  in  another, 
when  the  patient  had  gone  abroad  for  phthisis,  he 
became  sane ;  but  by  the  time  his  bodily  symptoms 
were  better,  it  was  necessary  to  bring  him  back  to 
England,  in  consequence  of  the  return  of  his  suspicions. 
A  second  advance  of  the  lung  disease  was  associated 
with  mental  improvement,  only  to  be  followed  by 
mental  relapse,  with  arrest  of  the  pulmonary  disease. 
In  the  end  phthisis  and  the  insanity  became  fully 
established,  and  he  died  obstinate,  deluded,  and  ex- 
hausted. It  is  not  uncommon  to  be  able  to  discharge 
such  cases  from  asylums  in  the  last  few  weeks  of 
their  existence  ;  and  every  year  I  am  in  the  habit  of 


Chap.  XVIII.]     Phthisis  and  Insanity.  399 

recommending  friends  to  take  sueli  patients  home 
to  die. 

To  sum  up.  This  class  consists  generally  of 
'  young  patients,  in  whom  phthisis  develops  slowly 
but  steadily ;  on  the  physical  side  emaciation,  haemop- 
tysis, and  diarrhoea  are  the  chief  and  only  symptoms, 
whereas,  mentally,  there  is  obstinate  or  stolid  melan- 
cholia, with  refusal  to  take  food,  depending  upon  hallu- 
cinations of  taste  and  smell,  or  delusions  about  poison, 
Other  hallucinations  may  be  present,  more  especially 
those  of  hearing ;  the  end  of  such  cases  is  almost  cer- 
tainly death.  Post-mortem  :  no  special  tubercular  con- 
ditions have  been  found  by  me  in  the  brain  ;  lung 
changes  as  well  as  fatty  changes  in  the  liver  have 
been  met  with. 

Phthisis  and  insanity.  —  William  C,  single, 
25  ;  mother  insane ;  first  attack  of  insanity  coming 
on  without  any  known  cause.  The  symptoms  were 
first  noticed  ten  weeks  before  admission,  and  were 
described  as  mental  and  physical  collapse.  He  wished 
he  was  dead,  and  thought  his  whole  body  was  polluted, 
so  that  he  must  destroy  it  to  get  a  new  one  ;  he  wanted 
his  head  blown  open.  He  believed  his  friends  were 
against  him.  On  admission  ho  wa:?  extremely  thin, 
and  very  obstinate  ;  he  would  take  no  food,  and  was 
wet  and  dirty.  He  had  no  cough  or  expectoration, 
slight  sweating,  temperature  higher  at  night.  Much 
rachitic  deformity  of  chest.  No  dulness,  or  other  signs 
of  phthisis.  Later,  dulness  was  noticed  at  right  apex, 
and  some  large  rales.  These  symptoms  slowly  in- 
creased, but  for  a  time  he  took  his  food  voluntarily. 
He  sank  and  died. 

A   second  group   includes    cases    which,    perhaps, 

scarcely  deserve  the  term  phthisis.    I  can  only  say  that 

several  which  have  been  under  my  care  have  not  pro- 

•  vided  me  with  bacilli,  therefore  that  they  were  phthisical 

at  all  remains  doubtful.   Cases  of  melancholia,  occurring 


400    Insanity  and  Allied  Neuroses.  [Chap,  xviii. 

later  in  life,  say  from  forty  to  sixty,  are  often  found 
after  death  to  have  large  cavities  in  the  lung,  and 
I  am  sure  that  there  is  a  very  distinct  connection 
between  the  lung  degeneration  and  the  weak  physical 
health  connected  with  the  melancholia.  I  have  seen 
one  or  two  cases  in  which  cataleptic  symptoms  have 
Leen  present  in  patients  who  have  died  with  lung 
disease ;  and  I  would  only  insist  upon  the  fact  that 
it  is  of  the  utmost  importance  to  examine  every  case 
of  melancholia,  whether  young  or  old,  whether  with  or 
without  general  symptoms,  for  lung  disease.  It  may  be 
well  here  to  allude  to  the  fact  that  gangrene  of  the  lungs 
was  supposed  to  be  especially  common  among  the  in- 
sane. In  my  experience  it  is  rare,  and  I  am  still  doubt- 
ful how  much  is  due  to  mechanical  causes,  such  as  the 
introduction  of  foreign  bodies  into  the  lungs  themselves. 

To  conclude,  phthisis  kills  a  large  number  of 
insane  patients. 

Phthisis,  especially  if  associated  with  neurotic 
taint,  produces  highly  unstable  nervous  systems. 

Phthisis  in  the  insane  is  associated  with  certain 
groups  of  symptoms  characterised  by  suspicion  and 
refusal  of  food  on  the  one  hand,  and  with  masking 
of  the  physical  symptoms  on  the  other. 

Degenerative  lung  disease  is  common  in  melan- 
cholia and  in  general  paralysis. 

Sanity  not  uncommonly  returns  before  death  in 
phthisical  lunatics,  and  some  recover  sanity  to  die  in 
a  year  or  two  of  phthisis. 

Spasmodic  asttimsi,  witli  insanity. — Spas- 
modic asthma  must  be  looked  upon  as  a  nervous 
disorder,  and  it  is  of  great  interest  and  importance 
to  be  able  to  trace  distinct  relationship  between 
it  and  other  nervous  disturbances.  I  have  met 
with  several  cases  in  which  insanity  has  alternated 
with  spasmodic  asthma  in  patients  who  have  for 
years  been  subject  to  recurrent  attacks   of  asthma, 


Chap,  xviii.j     Insanity  WITH  Asthma.  401 

and  wlio  have  become  almost  suddenly  well,  as  far 
as  the  asthma  was  concerned,  but  who  at  the  same 
time  developed  insanity,  and  as  long  as  the  in- 
sanity was  present  the  asthma  was  absent.  This 
alternation  of  symptoms  in  many  respects  resembles 
what  I  have  already  referred  to  as  occurring  with 
some  cases  of  hysteria.  Cases  which  I  shall  refer  to 
more  particularly  are  subjoined,  two  having  been 
discharged,  and  two  others  still  being  under  treat- 
ment. 

Elizabeth  G.,  single,  set.  34,  with  no  insane 
inheritance.  This  is  the  second  attack  of  insanity, 
the  first  having  occurred  five  years  ago.  There  was  a 
history  of  phthisis  in  the  family.  This  patient  had 
been  admitted  to  the  Incurable  Hospital  at  Putney 
in  consequence  of  the  chronic  asthma.  When  ad- 
mitted into  Bethlem  she  was  as  melancholic  and 
suicidal  a  case  as  one  could  well  see.  She  refused  her 
food  ;  she  thought  people  were  making  remarks,  and 
that  there  were  voices  and  accusations  of  every 
description  to  annoy  and  distress  her.  She  attempted 
suicide,  and  while  in  the  hospital  she  drank  off  all 
her  medicine,  hoping  thus  to  effect  her  object.  This 
condition  of  active  suicidal  melancholia  continued  till 
she  developed  an  attack  of  asthma,  after  which  she 
was  perfectly  sane,  and  for  a  time  had  few  re- 
currences of  asthma.  This,  however,  returned  with 
obstinate  violence,  and  at  present  she  is  subject  to 
recurrent  attacks  of  spasmodic  asthma,  but  retains 
her  sanity. 

Kate  M.,  single,  set.  28,  insanity  on  mother's 
side,  and  phthisis  on  the  father's  side.  Patient  has 
been  subject  to  neuralgia.  She  has  had  three  pre- 
vious attacks  of  insanity.  Soon  after  she  menstruated 
she  developed  symptoms  of  spasmodic  asthma,  which 
continued  till  1874,  when  she  had  her  first  attack  of 
insanity  ;  during  this  attack  she  was  free  from  asthma ; 

A  A — 14 


40  2      Insanity  and  Allied  Neuroses.  [Chap,  xviii. 

with  mental  health  asthma  returned.  "With  each 
fresh  attack  of  insanity  there  was  a  repetition  of  the 
bodily  and  mental  symptoms  met  with  in  the  first 
attack.  The  present  attack  began  six  weeks  before 
admission  (October,  1883).  She  was  maniacal;  she 
pricked  her  skin  to  allow  the  sand  to  escape  from 
under  it,  as  she  said.  She  saw  black  things  above 
her  and  in  her  food.  She  was  very  destructive  and 
abusive. 

She  was  obstinate  and  refused  her  food,  having  to 
be  forcibly  fed.  She  was  extremely  thin  and  weak. 
By  January,  1884,  she  was  well  enough  to  go  to  the 
Convalescent  Home,  and  for  a  short  time  had  peace  of 
mind  and  body ;  as  she  got  stronger  the  asthma  re- 
turned, and  she  was  discharged  well  mentally,  but 
suffering  from  spasmodic  asthma,  and  I  suppose  she 
will  continue  to  break  down  every  few  years. 

Matilda  K.,  single,  ?et.  32,  admitted  Feb.,  1884, 
no  insanity  in  the  family,  sister  died  of  tubercle  ; 
first  attack  of  insanity,  which  has  lasted  three 
months.  She  has  been  subject  to  spasmodic  asthma 
ever  since  puberty,  but  for  some  months  back  there 
has  been  a  change,  so  that  she  has  been  free  from 
asthma,  and  also  free  from  her  "delicacy  of  chest." 
The  immediate  cause  of  the  mental  disorder  was  said 
to  have  been  the  breaking  off  an  engagement. 
Amenorrhoea  has  lasted  since  August.  She  first 
became  slee^pless,  then  moody  and  taciturn ;  she  was 
emotional,  ajid  threatened  suicide  ;  she  thought  she 
was  going  to  hell,  and  saw  the  tortures  which  were 
being  prepared  for  her ;  she  saw  the  spirits  of  her 
dead  friends  ',  she  said  the  asthma  had  gone  to  her 
head,  and  had  destroyed  her  brain ;  that  her  skull 
was  empty ;  she  refused  food,  w^as  obstinate  and 
silent  \  she  was  a  good  example  of  melancholia,  with 
ideas  of  unworthiness  ;  she  had  hallucinations,  and  was 
bothered  by  hearing  voices  shouting  obscenities  at  her. 


Chap.  XVIII.]      Insanity  with  Asthma.  403 

Very  slowly  this  patient  gained  strength,  and  in  the 
end  recovered. 

In  one  other  case  chronic  bronchitis  was  replaced 
by  insanity. 

Ann  W.,  widow,  set.  64;  no  insane  relations  ;  had 
suffered  from  asthma  and  chronic  bronchitis  for  twenty 
years;  about  Christmas,  1883,  she  became  free 
from  bronchitis,  but  excited  mentally.  She  fancied 
people  were  talking  about  her ;  she  believed  people 
were  going  to  injure  her  and  her  son ;  she  was 
emotional  and  obstinate ;  she  said  her  food  did  not 
pass  through  her,  and  that  she  was  lost;  she  was 
suicidal,  threatening  to  injure  herself  with  knives,  or 
to  set  herself  on  fire ;  she  refused  food,  and  had  to  be 
artificially  fed. 

In  this  case  the  age  is  against  the  recovery  of  the 
patient. 

Obstinacy,  refusal  of  food,  and  suicidal  tendencies, 
with  hallucinations  of  the  senses,  and  delusions  as  to 
being  eternally  lost,  are  the  chief  symptoms  of  these 
cases. 

Dr.  Clifford  AUbutt  has  pointed  out  the  relation- 
ship between  spasmodic  asthma  and  some  abdominal 
neuroses,  and  I  expect  we  shall  find  similar  relation- 
ships between  some  of  the  abdominal  neuroses  and 
insanity,  so  that  a  hypochondriac  will  be  found  to  be 
free  from  his  hypochondriasis  when  acutely  insane. 

I  have  also  met  with  cases  in  which  nerve-storm 
headaches  have  been  entirely  absent  during  attacks  of 
insanity,  and  in  one  case  no  recurrence  of  these  nerve- 
storm  headaches  took  place  after  recovery  from  a 
severe  attack  of  melancholia. 


404 


CHAPTER   XIX. 

HEART   DISEASE    AND    INSANITY. 

Heart  disease  and  insanity — ^Acute  mania,  with  repeated  attacks  of 
rheumatism — Symptoms  resembliag  general  paralysis  asso- 
ciated with  advanced  aortic  disease — Kidney  disease  and 
insanity. 

It  is  fully  recognised  that  there  is  a  great  want  of 
careful  statistics  as  to  the  exact  j^troportion  in  which 
heart  disease  is  found  to  be  present  in  cases  of  in- 
sanity, though  it  is  well  known  as  a  common  cause  of 
nervous  diseases;  and  without  such  statistics  all 
that  I  can  do  is  to  record  my  experience  of  cases  in 
which  melancholia  or  mania  has  been,  at  all  events  in 
some  way,  associated  with  heart  disease.  I  have  met 
with  a  large  number  of  cases  of  insanity  in  which 
there  has  been  some  heart  affection,  most  frequently 
following  rheumatic  fever;  and  I  have  already  re- 
ferred to  my  belief  that  there  is  occasionally  associated 
with  rheumatic  fever  a  nervous  disorder  which  may 
develop  into  insanity ;  this  being  quite  independent 
either  of  the  hyperpyrexia  which  may  occur  with,  or 
of  heart  disease  which  may  follow,  the  rheumatism. 
I  have  been  impressed  by  observing  many  cases 
suffering  from  mitral  disease  also  being  subject  to 
melancholy.  In  fact,  melancholia  is  always  looked 
for  by  me  in  patients  who,  having  had  several  attacks 
of  rheumatism,  with  heart  affection,  become  insane. 
With  aortic,  or  with  both  aortic  and  mitral  disease,  the 
symptoms  may  be  either  melancholic  or  maniacal ;  but 
I  am  inclined  to  think  that  with  simple  aortic  disease 
and  with  hypertrophy  of  the  left  ventricle,  it  is  at 
least  not  uncommon  to  meet  with  acute  mania  and 
exaltation   of   ideas.      This   is   interesting  to  me  in 


Chap.  XIX.]    Heart  Disease  and  Insanity.  405 

connection  with  other  observations  which  I  have  made 
upon  the  same  subject.  In  patients  who  have  suflfered 
with  mental  disorder  resembling  in  many  particulars 
general  paralysis  of  the  insane  I  have  found  very 
marked  atheroma  of  the  aorta.  So  that  in  doubtful 
cases  of  men  with  exaltation  of  ideas  I  expect  to  find 
•post  mortem  hypertrophy  of  the  left  ventricle  and 
atheroma  of  the  aorta,  with  more  or  less  brain  change. 

In  the  following  case  there  was  acute  mania, 
with  repeated  attacks  of  rheumatism :  Sidney  C, 
single,  set.  22,  medical  student  \  had  had  four  at- 
tacks of  rheumatic  fever  already,  and  his  heart  was 
most  seriously  damaged.  This  was  the  first  attack  of 
insanity,  and  had  lasted  three  weeks,  and  followed 
directly  his  last  attack  of  rheumatic  fever.  It  began 
with  incoherence,  excitement,  and  sleeplessness.  He 
stated  he  was  going  to  Lord  Hartington ;  that  he  was 
to  have  a  peerage  and  £150,000  a  year  ;  that  he  was 
going  to  found  a  university  of  his  own ;  and,  in  fact, 
he  was  as  full  of  grand  ideas  and  benevolence  as  any 
general  paralytic  I  have  ever  met  with.  He  was  con- 
stantly writing  letters,  and  restlessly  moving  about. 
The  pulse  was  of  the  water-hammer  type,  and  double 
murmur  was  heard  at  the  base  of  the  heart.  With  iron 
and  general  tonic  treatment  he  became  better,  sleeping 
and  eating  well ;  he  was  finally  discharged  recovered. 

In  the  next  case,  symptoms  resembling  general 
paralysis  were  associated  with  advanced  aortic  disease. 
Osborne  O.,  single,  fifty-nine  years  old;  no  insane 
inheritance,  although  some  of  his  relatives  were  said  to 
have  suffered  from  spinal  disease.  The  first  symptom 
arose,  without  any  special  exciting  cause,  six  months 
before  his  admission.  He  wrote  insulting  letters  to 
his  relations,  became  excited,  constantly  talking  about 
himself,  the  many  speculations  he  was  going  into, 
and  the  fortune  he  intended  to  make  j  he  said  he  was 
governor  of  the  Australian  colonies.     He  also  became 


4o6       Insanity  and  Allied  Neuroses.  [Chap.  xix. 

dirty  in  some  of  his  habits,  and  had  an  entirely  false 
appreciation  of  the  value  of  things.  While  in  Beth- 
lem  he  was  constantly  excited,  talking  vehemently, 
with  all  the  inconstancy  and  benevolence  of  the 
general  paralytic.  It  was  discovered  that  his  heart 
was  much  hypertrophied,  that  there  was  double  mur- 
mur at  the  base )  and  there  was  a  question  as  to 
the  existence  of  a  mitral  systolic  murmur  as  well.  He 
became  weaker  in  mind,  and  more  emotional.  One 
day  after  breakfast,  a  year  from  his  admission,  while 
sleeping  he  suddenly  died  ;  and  'post  mortem  we  found 
a  firm,  somewhat  wasted  brain,  with  excess  of  fluid, 
but  without  any  marked  adhesions  between  arachnoid 
and  cortex,  but  with  very  marked  atheroma  of  the 
arteries.  There  was  degeneration  of  the  kidneys ; 
heart  weighed  eighteen  ounces,  with  strong  adhesions 
between  the  left  ventricle  and  the  pericardium  ;  the 
left  ventricle  much  enlarged  and  thickened,  with  the 
aortic  valves  involved.  The  pulse-tracing  in  this  case 
was  most  characteristic  of  forcible  action  of  the  left 
ventricle,  the  upstroke  of  the  tracing  being  one  and  a 
half  inches  long.  The  pathology  of  the  condition  was 
somewhat  involved,  and  I  was  unable  distinctly  to 
say  that  his  physical  condition  depended  entirely  or 
chiefly  on  valvular  conditions  ;  for  it  seemed  to  me 
that  the  adherent  pericardium,  interfering  with  the 
action  of  the  left  ventricle,  had  been  the  chief  factor 
in  the  production  of  the  hypertrophy  of  the  left  side 
of  the  heart. 

It  is  interesting  to  notice  that,  in  this  case  again, 
there  were  symptoms  of  exaltation,  with  suspicion  of 
general  paralysis  of  the  insane,  although  no  adhesions 
were  found  on  the  surface  of  the  brain  post  m^ortem,. 

To  conclude.  The  brain  must  be  very  seriously 
afiected  in  the  performance  of  its  functions  by  the  cha- 
racter of  the  supply  of  nourishment  which  is  provided 
for  it  by  the  heart.       One  knows  that   the   general 


Chap.  XIX.]  Kidney  Disease  AND  Insanity.  407 

aspect  of  anxiety  which  is  depicted  on  the  faces  of 
many  patients  suffering  from  heart  disease  is  recognis- 
able enough ;  and  that  this  anxiety  should  be  further 
developed  into  melancholia  is  easily  to  be  believed. 
For  the  healthy  performance  of  function  there  must  be 
not  only  a  sufficient,  but  a  regular  supply  ;  anything 
interfering  with  the  quantity,  quality,  or  regularity  of 
supply  may  upset  the  nervous  balance,  and  cause, 
on  the  one  hand,  anxiety,  with  sleeplessness  and 
vague  dread ;  on  the  other,  exaltation  of  ideas,  with 
emotional  instability. 

It  is  not  to  be  forgotten  that  cases  of  heart  disease, 
with  hypertrophy  of  the  left  ventricle,  may  be  difficult 
to  diagnose  from  ordinary  cases  of  general  paralysis  of 
the  insane. 

Kidney  disease  and  insanity. — There  are  at 
present  several  very  important  questions  to  be  con- 
sidered in  relation  to  kidney  degeneration.  It  re- 
quires to  be  determined  whether  the  theory  of  Gull 
and  Sutton  is  true,  that  there  is  a  general  fibroid  de- 
generation occurring  in  the  cases  in  which  ultimately 
the  renal  symptoms  are  most  marked ;  and  whether, 
besides  a  fibrosis  which  affects  the  arteries  and  ab- 
dominal viscera,  there  is  also  a  fibrosis  of  the  brain. 
At  one  time  I  was  induced  to  examine  the  kidneys  of 
very  many  general  paralytics  who  had  died  in  Beth- 
lem,  but  with  only  negative  results  ;  for  after  com- 
])aring  the  structure  of  forty  kidneys  from  such  cases, 
I  was  unable  to  find  any  really  characteristic  change  of 
the  fibroid  nature  in  them.  But  although  I  have  not 
been  able  to  establish  any  definite  connection  between 
fibroid  degeneration  in  the  kidneys  with  any  group  of 
cases  of  general  paralysis,  yet  I  have  found  a  number 
of  cases  of  insa;nity  in  which  there  has  been  marked 
degeneration  of  the  kidneys.  And  although  I  cannot 
pretend  to  have  discovered  a  renal  insanity,  I  think  it 
is  worth  while  to  record  cases  in  which  kidney  disease 


4o8        Insanity  AND  Allied  Neuroses.  [Chap.xix. 

has  been  at  least  associated  with  insanity,  guarding 
myself  by  saying  that  I  fully  recognise  the  fact  that 
insane  persons  must  die  of  some  disease  sooner  or 
later,  and  that,  therefore,  it  is  only  natural  to  expect  we 
should  meet  with  kidney  disease  in  the  insane  as  well 
as  in  the  sane.  It  is  not  common  to  meet  with  albumi- 
nuria in  acute  cases  of  insanity,  and  I  may  say  this 
after  examining  several  hundred  specimens  of  urine  of 
the  insane. 

In  the  following  cases,  which  I  shall  give  in  brief, 
the  patients  were  suffering  from  melancholia ;  they 
had  "mania  of  suspicion";  they  all  died,  one  by  his 
own  hand  while  on  leave  of  absence. 

Kidney  disease^  melancholia,  urcemic  convulsions, 
death. — Clara  L.,  single,  set.  35,  governess  ;  anxiety 
was  the  supposed  cause  of  this  her  first  attack.  It 
had  lasted  six  months.  She  had  no  insane  relations. 
She  became  depressed,  declining  to  answer  questions  ; 
she  thought  her  friends  were  unkind  to  her  ;  she  wan- 
dered about  the  house  without  an  object ;  at  times  she 
was  violent,  attempting  to  bite  her  relations ;  she  was 
dirty  and  untidy.  She  had  hallucinations  of  sight 
and  hearing ;  she  thought  she  was  very  wicked,  and 
that  Grod  was  angry  with  her.  She  was  also  suffering 
from  amenorrhoea  of  some  months'  duration.  On  ad- 
mission, what  struck  one  most  was  the  prominence  of 
her  eye-balls,  the  right  being  extremely  protruded.  On 
examination  with  the  ophthalmoscope,  neuritis  in  both 
eyes  was  detected,  both  optic  nerves  being  swollen, 
veins  dilated  and  tortuous,  numerous  small  hsemor- 
rhages  and  white  patches,  the  right  eye  having  these 
most  marked.  Albumen  was  found  to  be  present  in 
the  urine  in  large  quantities.  Her  general  health  im- 
proved during  the  next  few  months,  when  she  was 
found  one  morning  unconscious,  having  lost  a  con- 
sidei-able  amount  of  power  on  the  left  side.  Her 
speech  was  thick  and  indistinct,  and  she  was  unable  to 


Chap.  XIX.]  Insanity  with  Kidney  Disease.         409 

swallow  solids.  Two  months  later  slie  had  another 
series  of  convulsions,  in  which  her  head  was  turned  to 
the  right  side  ;  breathing  became  stertorous,  and  nine 
hours  after  the  convulsions  she  died.  Post-mortem  : 
besides  wasting  of  the  cortex  of  both  kidneys,  with 
adherence  of  the  capsules,  the  condition  of  the  brain 
was  noteworthy.  The  lateral  ventricles  were  enor- 
mously dilated ;  in  fact  the  large  amount  of  fluid  in 
these  ventricles  had  pressed  the  convolutions  to  such  a 
degree  that  they  were  almost  smoothed  out,  and  the 
ventricular  walls  had  the  appearance  of  those  of  a 
case  of  hydrocephalus.  I  have  no  doubt  that  this 
case  would  have  been  looked  upon  in  former  days 
as  one  of  serous  apoplexy  j  and  it  is  interesting  to 
note  that  there  was  so  much  fluid  eflusion  into  the 
ventricles,  and  no  dropsy  elsewhere. 

The  second  case  was  that  of  Robert  S.  T.,  surgeon, 
married,  set.  60,  with  no  insane  relations.  He  had 
suffered  from  albuminuria  for  eight  years  ;  but  mental 
symptoms  had  only  lasted  four  months,  and  they 
began  with  religious  despair.  He  refused  to  eat,  as- 
serting that  his  relations  were  placing  drugs  and  dele- 
terious substances  in  his  food.  He  was  excitable,  and 
aimlessly  wandered  from  room  to  room.  He  thought 
he  was  lost,  and  that  he  was  a  hypocrite.  He  had 
ceased  to  take  any  interest  in  his  profession.  On  ad- 
mission he  had  hallucinations  of  taste  j  he  believed  he 
had  some  infectious  disease,  and  that  his  soul  was 
everlastingly  lost ;  refused  food,  and  slept  badly. 
During  the  time  he  was  in  the  hospital  he  remained 
in  much  the  same  state,  so  that  he  declined  to  enter 
into  any  friendly  communications  with  any  one.  He 
became  more  feeble,  and  died.  In  his  case  there  was 
nothing  found  post  mortem  beyond  the  ordinary  con- 
tracted kidneys  ;  and  the  question  is  if  old-standing 
Bright's  disease  alone  led  to  dread,  anxiety,  and  re- 
fusal to  take  food,  and  thus  developed  the  melancholia. 


4IO     Insanity  and  Allied  N'euroses,  [Chap.  xix. 

The  last  case  is  that  of  John  V.,  draper,  married, 
set.  46,  who  had  one  sister  suffering  from  an  attack 
of  mania.  This  was  his  first  attack  of  insanity,  and 
the  symptoms  followed  anxiety  and  worry  during 
the  previous  year,  the  worry  being  due  to  money  difii- 
culties.  His  first  complaints  were  of  pains  in  the  head. 
He  was  sleepless;  complained  of  voices  and  loss  of 
memory,  and  wandered  about  the  house  at  night ;  at 
times  he  was  violent,  suspicious,  and  fancied  people 
had  taken  property  belonging  to  him.  On  admission 
he  was  melancholic,  taking  little  notice  of  his  surround- 
ings, and  unable  to  give  a  connected  account  of  himself. 
Within  a  few  months  of  admission  it  was  noticed  that 
he  was  suffering  from  albuminuria ;  his  feet  became 
swollen,  and  his  face  puffy ;  with  the  swelling  of  his 
legs  and  the  physical  distress,  he  improved,  and  was 
so  much  better  that  he  was  sent  to  our  convalescent 
home,  and  later  was  allowed  to  go  on  leave.  One  day, 
without  any  special  alteration  in  his  symptoms,  he 
avoided  his  friends,  and  managed  to  commit  suicide  by 
hanging.  In  his  case  the  complaints  he  made  of  ex- 
treme sleeplessness  before  he  was  admitted  into  Beth- 
lem  inclined  me  to  think  that  while  on  leave  the  sleep- 
lessness recurring  caused  him  to  lose  power  of  self- 
control  ;  and  hence  his  suicide.  That  the  first  and  the 
last  cases  were  due  to  anxiety  I  have  little  or  no 
doubt.  The  evidence  given  by  the  patients  and 
their  friends  was  sufficiently  clear,  and  it  is  becoming 
more  plainly  demonstrated  that  anxiety,  or,  if  I  may 
use  the  term,  perpetual  strain  and  high  tension,  may 
give  rise  to  kidney  disease,  so  that  the  causation  of 
the  mental  symptoms  was  probably  of  a  two-fold 
nature,  strain,  anxiety,  and  sleeplessness  producing 
arterial  change,  and  this  tending  to  unstable  nervous 
conditions  ending  in  insanity. 


411 


CHAPTER  XX. 

DIABETES    AND    INSANITY. 

Diabetes  with  insanity — Exophthalmic  goitre — Myxcedema. 

The  question  as  to  the  causation  of  diabetes  remains 
as  far  from  solution  as  ever.  Notwithstanding  the 
discussion  at  the  Pathological  Society  during  the  ses- 
sions 1882-83,  the  relation  of  sugar  in  the  urine, 
either  to  nutritional  disorder  or  to  change  of  any 
kind  in  the  nervous  centres,  remains  unsettled.  In 
my  opinion  there  appear  to  be  several  strong  reasons 
against  considering  diabetes  to  be  merely  a  nervous  dis- 
ease. In  the  first  place  there  are  certainly  no  common 
changes  found  in  the  brain  and  higher  centres  in 
diabetes  ;  and  next,  it  is  uncommon  to  find  this  dis- 
ease well  marked  among  insane  patients.  IsTotwith- 
standing  the  observations  made  by  Dr.  Dickinson  at 
Bethlem  Hospital  some  years  ago,  in  which  he  dis- 
covered traces  of  sugar  in  a  considerable  number 
of  cases,  1  am  convinced  that  some  error  crept  into 
those  experiments  ;  and  I  am  inclined  to  think  that 
the  reduction  of  the  copper  which  took  place  was 
rather  due  to  the  presence  of  uric  acid  than  of  sugar. 
At  all  events,  on  careful  repetition  of  the  investiga- 
tion in  the  spring  of  1883  with  Dr.  Hale  White,  I 
was  confirmed  in  my  belief  by  finding  sugar  in  only 
three  cases  in  the  hospital.  There  is,  however,  accord- 
ing to  Dr.  Maudsley  and  others,  a  relationship  of 
another  kind  between  neuroses  and  diabetes  ;  diabetes, 
according  to  these  observers,  occurs  in  the  same  families 
in  which  insanity  is  also  present.  I  have  not  as  yet 
made  sufficiently  numerous  or  careful  inquiries  as  to 
the  truth  of  this  observation,  but  I  must  admit  I  have 
already  met  with  several  cases  confirming  it. 


412       Insanity  and  Allied  Neuroses.   [Chap.  xx. 

In  the  three  following  cases  sugar  was  found  in 
considerable  amount  in  the  urine.  One  patient  (J.) 
with  brain  hypochondriasis,  who  believed  that  he  had 
lost  his  "  back  brain"  and  with  it  the  power  of  thought. 
The  second  case  (H.)  was  peculiar  from  many  points 
of  view.  This  man  was  of  advanced  years,  and  his  in- 
sanity depended  upon  post-apoplectic  conditions.  After 
the  attack  of  apoplexy  it  was  discovered  that  he  was 
passing  a  moderate  amount  (thirty  to  forty  ounces) 
of  urine  daily,  of  specific  gravity  luider  1*020,  with 
a  considerable  amount  of  sugar.  The  sugar  may  have 
been  altogether  independent  of  the  apoplexy  and  the 
insanity  ;  for  the  patient  has  sufficiently  recovered  to 
be  discharged,  but  sugar  is  still  present  in  the  urine. 
In  the  third  case,  the  sugar  occurred  after  an  attack 
of  puerperal  insanity,  and  I  believe  that  it  will  be 
found  not  to  be  uncommon  for  sugar  to  appear  in  cases 
of  puerperal  insanity  in  which  the  milk  secretion  has 
been  arrested.  To  sum  up,  I  know  of  no  direct  re- 
lationship between  diabetes  and  insanity. 

Exophthalmic  goitre  TFith  iiiisanity. —  In 
referring  to  myxoedema  I  point  out  the  interesting 
connection  existing  between  degeneration  and  altera- 
tion in  the  peripheral  and  central  nervous  systems,  and 
the  relationship  of  these  changes  to  the  development 
of  symptoms  of  insanity  ;  here  too  a  similar  interest 
exists,  for  with  exophthalmic  goitre  we  have  a  strange 
perversion  which  must  be  considered  as  more  or  less 
intimately  connected  with  the  sympathetic  system,  or 
at  all  events  I  may  safely  say  the  vaso-motor  systems  ; 
and  as  in  myxoedema  we  had  disease  of  the  ordinary 
nerve  tissues,  so  here  the  nerve  tissues  of  organic  life 
seem  to  be  implicated.  It  is  unnecessary  to  describe 
in  full  the  symptoms  of  this  disease,  suffice  it  to  say 
that,  as  with  myxoedema,  the  disorder  is  most  com- 
mon in  women.  Its  chief  symptoms  are  palpitation 
of  the  heart,  a  rapid  pulse,  prominent  eye-balls,  and 


Chap.  XX.]  Exophthalmic  Goitre.  413 

enlargement  of  tlie  thyroid  gland.  Its  relationship  to 
myxcedema  has  latterly  been  further  established  by  the 
remarkable  observations  made  in  Switzerland,  to  the 
effect  that  removal  of  the  thyroid  gland  may  be  asso- 
ciated with  development  of  myxoedematous  symptoms. 
In  the  Guy's  Hospital  Heports,  vol.  xxvi.,  I  have  de- 
scribed the  relationship  between  exophthalmic  goitre 
and  insanity,  and  I  will  here  briefly  recall  the  chief 
facts  observed. 

It  is  not  necessary  for  all  the  symptoms  to  be 
present  in  each  individual  case  ;  the  palpitation,  the 
prominent  eyes,  or  the  enlarged  thyroid,  may  be  the 
first  or  only  symptom  for  a  considerable  period,  but 
as  a  rule  all  the  symptoms  are  present  sooner  or  later. 
In  Bethlem  I  have  seen  three  fully  developed  cases  of 
this  disease  connected  with  insanity.  The  following  is 
a  good  example  : 

C.  S.,  single,  set.  28,  admitted  in  1877,  an  artist, 
having  two  insane  relations.  This  was  the  first  attack 
of  unsoundness  of  mind,  the  cause  being  unknown. 
Two  months  before  admission  into  Bethlem  she  be- 
came incoherent,  was  noisy  and  excitable,  had  delu- 
sions^ thought  that  she  was  an  actress,  and  had  false 
ideas  of  her  powers  and  influence.  The  chief  charac- 
teristics of  her  insanity  were  excitement,  incoherent 
talking,  violence,  destructiveness,  and  sleeplessness. 
She  had  suffered  a  good  deal  from  palpitation  of  the 
heart ;  according  to  her  friends,  exophthalmic  goitre 
had  been  developing  for  about  a  year,  and  she 
had  worried  herself  considerably  about  the  change  in 
her  personal  appearance.  On  admission  she  was 
found  to  be  a  pale,  anaemic  girl,  with  marked  and 
pretty  uniform  protrusion  of  both  eye-balls,  and  slight 
enlargement  of  the  thyroid  gland.  The  number  of  the 
pulse  was  not  then  recorded,  but  later  it  was  140  to 
the  minute.  She  continued  to  be  acutely  maniacal 
during  the  next  month,  became  filthily  dirty  in  her 


414      Insanity  and  Allied  Neuroses.   [Chap.  xx. 

habits,  constantly  filling  her  mouth  with  dirt,  stones, 
and  sticks.  She  was  treated  medically  with  liquor 
ergotse  and  tinctura  belladonnas,  but  without  any 
benefit.  Within  ten  weeks  of  her  admission  she  be- 
came much  weaker,  and  was  confined  to  her  bed.  She 
suffered  much  from  vomiting  and  purging ;  the  pulse 
was  135,  respirations  40,  temperature  98^.  The  eyes 
were  more  prominent  than  ever,  especially  the  left ; 
the  pupils,  which  at  first  were  large,  became  somewhat 
larger ;  she  was  still  dirty  in  her  habits,  but  less 
noisy  ;  palpitation  of  the  heart  was  marked,  and  a 
systolic  bruit  was  heard  at  the  base  of  the  heart.  This 
was  very  rough  in  character,  but  was  not  audible  at 
the  apex.  A  bruit  also  occurred  at  the  base  of  the 
neck  on  both  sides.  The  patient  now  became  dull  and 
sleepy,  skin  hot  and  dry  to  the  touch,  although  the 
temperature  was  really  normal.  She  became  more 
dull  and  sleepy,  and  could  hardly  be  roused.  Pulse 
140,  respirations  50,  temperature  100°.  ISTo  lung 
complications  could  be  detected ;  heart  palpitating ; 
conjunctivse  suffused,  optic  discs  pale,  vessels  appeared 
large  and  dilated ;  the  vomiting  became  less,  purging 
continued.  On  the  next  day  she  was  reported  to 
be  gradually  sinking.  Post-mortem  :  the  brain  was 
found  to  weigh  44|^  oz.,  the  dura  mater  was  thick,  but 
free,  the  arachnoid  thin  and  quite  normal.  There  was 
an  appearance  of  congestion  about  the  finer  vessels, 
giving  a  bright  red  dendroidal  appearance  to  the  sur- 
face of  the  brain.  There  were  no  local  wastings  of 
the  convolutions  ;  there  was  slight  excess  of  subarach- 
noidal fluid ;  grey  matter,  normal  but  thin ;  white 
matter,  soft ;  ventricles  with  excess  of  fluid,  walls  and 
floors  of  ventricles  granular,  vessels  at  base  normal ; 
cervical  sympathetic  ganglia  normal  in  appearance  ; 
lungs  congested  at  base,  and  having  several  patches  on 
the  surface  like  apoplexies.  Heart  \Z\  oz.,  firmly 
contracted  ;  early  atheroma  visible  in  the  aorta  ;  clot 


Chap.  XX.]         Exophthalmic  Goitre.  ^\^ 

in  the  right  auricle.  Both  kidneys  congested,  capsule 
thick  and  adherent ;  liver  very  fatty ;  suprarenal 
capsules  small  and  breaking  down.  There  was  some 
fulness  in  Peyer's  patches,  and  the  s^^leen  was  normal. 
On  careful  microscopical  investigation  of  the  cervical 
ganglia  of  the  sympathetic,  perfectly  healthy  appear- 
ances were  found.  I  have  never  examined  a  more 
typically-healthy  sympathetic  in  my  life.  The  case, 
then,  so  far  as  the  post-mortem  is  concerned,  exhibits 
no  special  disease  except  in  the  suprarenal  bodies. 
The  congestion  in  Peyer's  patches  were  remarked  in 
connection  with  the  fact  that  similar  conditions  have 
been  described  by  Mr.  Howse,  in  the  "  Pathological 
Transactions"  for  1877,  as  having  been  found  in 
another  case  of  this  disease. 

In  all  the  three  cases  recorded  in  the  Guy's  Hos- 
pital Peports  there  was  present  a  restless  condition  of 
mental  irritability  and  violence,  with  dirty  habits,  re- 
fusal of  food,  emaciation  and  diarrhoea,  and  in  two  of 
them  death.  I  was  unable  to  convince  myself  of  any 
change  in  the  cervical  ganglia  of  the  sympathetic. 
Other  cases  have  been  described  more  recently  by  Dr. 
Carlyle  Johnstone,  and  I  have  no  doubt  that  now  the 
relationship  has  been  pointed  out  it  will  be  seen  to 
be  more  common  than  might  have  been  imagined. 
Besides  ordinary  insanity  associated  with  this  con- 
dition, I  have  met  with  several  cases  of  general  para- 
lysis of  the  insane,  with  one  or  all  of  the  symptoms  of 
this  disease  ;  and  other  writers  have  described  proptosis 
as  an  accompaniment  of  general  paralysis.  I  am  per- 
suaded that  in  cases  where  this  proptosis  was  present 
other  symptoms  would  have  been  found  if  sought  for. 

The  third  condition  of  interest  is  that  in  which 
there  are  recurrences  of  mental  and  bodily  symp- 
toms together.  One  patient,  at  present  in  Bethlem, 
subject  to  recurrences  of  mental  excitement,  always 
exhibits  a  prominence  of  eyes  with  a  rapid  pulse  and 


41 6      Insanity  AND  Allied  Neuroses.   [Chap.  xx. 

a  somewhat  enlarged  neck  among  the  earliest  symp- 
toms of  the  recurrence  ;  and  that  this  is  not  a  singular 
example  I  am  convinced,  not  only  from  my  own 
observations,  but  from  the  inspection  of  photographs 
of  cases  of  recurrent  mania  during  the  periods  of 
excitement  and  of  rest,  which  I  have  met  with  from 
time  to  time. 

To  sum  up.  With  insanity  there  may  occur  all  of 
the  symptoms  of  Graves's  disease,  and  this  condition 
may  be  a  permanent  progressive  one ;  so  that  the 
patients  die  of  Graves's  disease  with  insanity,  or  they 
may  die  of  general  paralysis  in  which  exophthalmos 
with  rapidity  of  pulse  has  been  present  constantly,  or 
recurrently,  or  periodically  \  symptoms  of  sjanpathetic 
disturbance  may  also  be  associated  with  recurrent 
mental  disorder.  The  treatment  of  such  cases  must  de- 
pend rather  upon  general  than  upon  special  symptoms, 
and  I  may  say  I  have  met  with  several  cases  of  acute 
mental  disorder  with  symptoms  of  exophthalmic  goitre, 
which  have  completely  recovered,  and  have  lost  both 
the  symptoms  of  mental  disorder  and  those  of  bodily 
disease. 

Myxoedenia  and  insamty. — I  have  special 
interest  in  considering  this  condition  and  its  relation- ' 
ship  to  insanity,  because  I  believe  I  was  the  first  in 
England  to  describe  this  relationship,  and  since  my 
description  many  other  writers  have  recognised  its 
force.  I  annex  a  likeness  of  a  case  in  which  myxoe- 
dema  was  well  marked.  I  am  convinced  that  there 
is  some  very  special  connection  between  the  alteration 
in  the  type  of  face  and  conditions  allied  to  myx- 
csdema.  A  certain  number  of  weak-minded  patients 
assume  aspects  strikingly  similar,  and  one  special 
group  had  long  been  recognised  by  me  before  I  knew 
anything  of  myxoedema.  These  are  not  fully  deve- 
loped cases  af  this  disease,  but  I  believe  they  will  be 
found   to   have   much   in   common  with   it.       With 


Chap.  XX.] 


Myxcedema. 


417 


myxcedema,  as  has  been  pointed  out  by  Gull  and 
Ord,  a  certain  cretinoid  appearance  becomes  developed 
in  patients  formerly  healthy,  and  with  this  condition 
a  slowness  of  nervous  reaction  is  also  present. 
Patients    have,  in    fact,  alteration    not   only  in    the 


A  case  of  Myxcedema  with  Weakness  of  Mind. 

peripheral  nerve  endings,  but  also  in  the  higher 
centres,  so  that  perception  is  dull  and  conduction 
slow,  the  reaction  having  been  likewise  impaired. 
Which  of  these  plays  the  most  important  part  in  the 
production  of  the  mental  weakness  I  am  not  pre- 
pared to  say ;  but  I  have  sufficiently  referred  to  the 
B  B — 14^ 


41 8        Insanity  and  Allied  Neuroses.  vOi-x-^.^y.. 

importance  of  normal  sense  perception  in  producing 
healthy  nervous  action,  and  need  say  no  more  on  the 
subject,  but  proceed  to  give  an  example  of  insanity 
with  myxoedema. 

Sarah  B.,  widow,  set.  60 ;  had  had  one  previous 
attack  of  insanity,  the  supposed  cause  being  the  death 
of  her  husband.  A  maternal  aunt  had  suffered  from 
insanity  also.  The  symptoms  of  this  attack  occurred 
three  months  after  the  death  of  her  husband,  and 
about  three  months  before  admission  into  Bethlera. 
The  first  symptoms  were  incoherent  letter-writing  and 
hallucinations  of  sight.  She  became  threatening  and 
violent ;  fancied  people  were  insulting  her.  She  was 
feeble  in  memory  and  complained  of  people  watching 
her,  speaking  about  her,  and  wishing  to  starve  and 
annoy  her.  Tliese  symptoms  exhibit  nothing  specially 
characteristic,  being  similar  to  those  commonly  met 
with  in  elderly  widows  of  a  nervous  type  ;  but  on 
careful  investigation  it  was  found  that  her  perception 
was  very  dull,  temperature  sub-normal,  her  aspect  fully 
myxoedematous,  her  speech  slow  and  muffled.  She 
has  a  sense  of  suspicion  and  of  injury  such  as  I  have 
described  as  common  in  these  cases.  The  prognosis 
in  all  such  cases  appears  to  me  to  be  unfavourable. 
It  depends  rather  upon  the  bodily  condition  and  upon 
the  secondary  degenerations  which  may  occur  during 
the  development  of  the  disease.  In  the  above  case  no 
albumen  is  present  in  the  urine,  therefore  one  may 
expect  this  patient  to  continue  slowly  to  develop  the 
symptoms  already  described  for  years  to  come,  and 
then  she  will  die  of  some  secondary  disease  at  an 
advanced  age. 

The  following  is  an  example  of  myxoedema  in  an 
early  stage  in  a  man.  George  E.,  hairdresser,  married, 
set.  37  ;  no  insane  relations.  This,  his  first  attack  of 
insanity,  had  lasted  three  weeks  before  his  admission, 
oil  September  24,  1883.     It  began  with  suspicion  that 


Chap.  XXL]      Alcoholism  and  Insanity.  419 

a  young  man  was  going  to  kill  liis  wife ;  lie  thought 
his  food  was  poisoned ;  he  was  restless,  sleepless,  and 
much  depressed ;  had  hallucinations  of  hearing ;  he 
could  not  control  his  thoughts ;  constantly  "  bad  lan- 
guage appealed  to  him." 

Slowly  this  patient  gained  confidence  in  himself  up 
to  a  certain  point,  but  there  he  again  failed.  He  was  tried 
at  home  but  could  not  manage  to  stay  there,  voices  and 
followers  annoyed  him.  He  occupied  himself  in  pho- 
tography, but  preferred  to  remain  in  the  hospital. 

Physically  this  patient  exhibits  the  symj^toms  of 
myxoedema  only  to  a  moderate  degree,  but  they  are 
all  increasing.  His  face  is  becoming  cretinoid  ;  his 
temperature  is  sub-normal ;  his  skin  is  hard  and  does 
not  sweat ;  his  sight  is  impaired  and  his  hearing  is 
failing.  Slowly  but  steadily  he  will  pass  into  dementia. 
No  treatment  will  be  of  any  use. 


CHAPTER    XXL 

ALCOHOLISM   AND    INSANITY. 

Alcohol  as  a  cause  of  insanity— a.  Directly  as  in  alcoholism — 
h.  Indirectly  as  producing  gout,  renal  disease,  arterial  de- 
generation.— a.  (1)  Acute  alcoholism — (Delirium  tremens) — 
Acute  alcoholism  in  neurotic  persons — Acute  alcoholism  in 
persons  suffering  from  head  injury — Acute  alcoholism  in 
persons  suffering  from  physical  weakness. — (2)  Chronic  al- 
coholism, producing  sense  perversions,  with  hallucinations, 
giving  rise  to  ideas  of  persecution  or  of  jealousy— Chronic 
alcoholism  with  moral  perversion,  convulsive  and  jDaralytic 
seizures,  general  jparalysis,  dementia — Dipsomania — Opium 
and  morphia-taking — Chloral-taking — Tobacco  and  insanity — 
Chloroform-taking — Insanity  due  to  lead  poisoning — Gout 
with  insanity — Post-febrile  insanity — Insanity  following  deli- 
rium— Weakness  of  mind  following  feverish  state  —  Moral 
perversion  following  feverish  state. 

The   role  which    alcohol  plays    in  the  causation    of 
insanity  has  already  been  briefly  referred  to. 


420        Insanity  and  Allied  Neuroses.  [Chap.  xxi. 

I  have  now  to  consider  the  forms  of  insanity 
which  owe  their  origin  specially  to  this  agent. 

To  one  great  class  of  reformers  alcohol  is  the  general 
cause  of  insanity,  and  is  directly  to  be  blamed  for  the 
supposed  increase  of  the  disorder  among  the  people. 
I  have  no  doubt  but  that  among  some  classes  it  is 
quite  true  that  drink  is  the  chief  cause  of  mental  dis- 
order, just  as  it  undoubtedly  is  of  social  disturbance.  It 
has  been  shown  that  insanity  increased  directly  with 
the  power  of  the  working  classes  to  get  drink,  and 
decreased  in  times  of  distress  in  which  money  could 
not  be  got  to  provide  stimulants. 

Drink  may  cause  insanity,  and  it  is  chiefly  harm- 
ful under  certain  conditions  to  which  I  shall  refer. 

Drink  often  gets  blamed  for  producing  insanity, 
whereas  the  intemperance  was  the  first  symptom  of 
the  disease. 

Intemperance  in  the  use  of  stimulants  may  act 
as  a  direct  poison,  at  once  affecting  the  whole  nervous 
system,  or  it  may  affect  the  man  by  throwing  him 
out  of  his  social  circle  into  a  lower  one,  and  thus,  by 
producing  poverty  and  loss  of  caste,  act  and  react  on 
the  unstable  mind.  Alcoholic  excess  may  act  directly 
on  the  nervous  tissues,  or  primarily  on  the  general 
organs  of  secretion  and  excretion,  interfering  with 
the  depuration  of  the  blood,  and  thus  act  by  prevent- 
ing the  brain  from  being  properly  nourished. 

Alcoholic  excess,  then,  may  be  the  predisposing 
cause  of  insanity ;  may  be  the  exciting  cause  ;  or  may 
only  be  a  symptom  of  the  disorder. 

There  seems  to  be  a  great  deal  of  misunderstand- 
ing about  the  legal  relationship  of  insanity  to  drink, 
and  I  shall,  when  describing  the  legal  relationship  of 
insanity,  have  occasion  to  point  out  the  various  de- 
grees of  responsibility  which  exist  with  intemperance 
in  drink. 

That  insanity  of  a  definite  kind,  and  having  special 


Chap.  XXI.]  Alcoholism.  421 

symptoms  originated  in  intemperance,  does  not  in  any 
way  affect  tlie  fact  that  insanity  is  present. 

Almost  every  variety  of  insanity  may  be  started 
by  drink  ;  but  there  are  also  special  symptoms  con- 
nected with  poisoning  of  the  nervous  tissues.  I  shall 
point  out  that  poisoning  by  opium  or  other  drugs 
may  give  rise  to  similar  symptoms. 

The  most  practical  question  is  whether  persons 
suffering  from  alcoholic  insanity  should  be  sent  to 
asylums.  If  suffering  from  simple  acute  alcoholism, 
or  if  suffering  from  delirium  tremens,  it  is  best  not  to 
send  them  to  lunatic  asylums ;  though  a  superinten- 
dent is  justified  in  receiving  a  dangerous  alcoholic 
case,  and  will  be  held  free  by  the  law  if  certificates 
have  been  duly  filled,  and  the  order  and  statement  are 
in  proper  form.  In  some  cases  the  sending  such  a 
patient  to  an  asylum  has  a  beneficial  efiect,  at  least 
for  a  time.  I  have  known  several  hard  drinkers  be- 
come sober  for  considerable  periods  when  they  dis- 
covered their  nearness  to  ordinary  insanity. 

The  great  danger  of  admitting  such  cases  is  that 
they  rarely  appreciate  the  intention  of  their  friends, 
and  are  commonly  vindictive.  Such  cases,  too,  are 
frequently  morally  perverse  and  sly;  trumped-up 
accusations  and  vexatious  law-suits  are  constant 
sources  of  worry  as  a  result  of  their  admission. 

Drinking  may  be  an  early  symptom  of  insanity. 
It  may  occur  in  cases  where  restlessness  and  sleepless- 
ness are  the  early  symptoms  of  disorder.  It  may  occur 
in  cases  of  hypochondriasis  with  anorexia.  It  may  be 
part  of  the  loss  of  control  of  the  appetites  seen  in 
general  paralysis  of  the  insane.  It  may  be  the  result 
of  insane  habit,  which,  from  taking  "  nips,"  has 
developed  into  taking  to  excess.  It  may  grow  out  of 
the  craving  of  pregnancy,  or  it  may  be  a  symptom  of 
climacteric  uneasiness.  It  may  be  a  direct  inheritance, 
or  it  may  be  a  result  of  neurotic  inheritance. 


42  2        Insanity  and  Allied  Neuroses.  [Chap.  xxi. 

1  shall  not  describe  delirium  tremens  in  full. 
It  is  sufficiently  recognised  and  described  by  the 
general  physician.  It  may  be  the  result  of  one  de- 
bauch \  it  may  follow  prolonged  drinking ;  it  may 
follow  an  injury  or  a  mental  shock  in  persons  who 
have  been  intemperate.  I  believe,  in  such  cases,  joyous 
news  may  also  upset  the  balance.  There  may  be  one 
or  many  attacks  of  delirium  tremens.  If  many 
attacks,  there  is  almost  certain  to  be  some  other  sign 
of  mental  weakness. 

I  have  made  a  distinction  between  delirium 
tremens  and  acute  alcoholism,  for  the  following 
reason.  I  have  seen  several  cases  in  whom  a  single 
short  bout  of  drinking  has  started  acute  delirious  mania 
in  highly  neurotic  subjects.  The  causes  of  the  attack 
and  the  general  symptoms  have  resembled  mania 
more  than  delirium  tremens. 

In  one  case  a  young  married  man,  whose  father 
was  distinctly  neurotic,  and  whose  sister  had  been 
seen  by  me  sufiering  from  mania  and  refusal  of  food, 
took  steadily  to  drinking.  He  was  a  restless,  active- 
minded  man,  who  was  trying  to  make  a  fortune 
rapidly  by  speculation.  He  felt  his  own  danger,  and 
the  day  before  I  saw  him  he  consulted  a  physician, 
and  got  a  narcotic  drau&'ht.  The  same  nio^ht  he 
became  wildly  excited  and  violent,  and  had  to  be 
restrained.  When  T  saw  him  early  the  next  morning 
his  face  was  flushed,  his  tongue  furred  and  tremulous. 
He  was  at  one  moment  shouting  at  the  top  of  his  voice, 
and  the  next  he  was  quiet  and  fairly  self-possessed. 
He  had  but  few,  if  any,  hallucinations  of  sight,  and 
had  no  true  horrors.  He  was  erotic,  and  took  food 
fairly.  I  told  his  friends  that  I  believed  it  would  turn 
out  to  be  a  case  of  iu sanity  started  by  delirium 
tremens,  and  this  proved  to  be  the  case.  All  the 
tremulousness  passed  off;  his  tongue  became  clean, 
and  incoherence,    sleeplessness,  and    chattering  were 


Chap.  XXL]  Acute  Alcoholism.  423 

the  symptoms  of  an  attack  of  mania,  from  which  he 
recovered. 

In  the  next  case  more  violent  delirium  tremens 
was  followed  by  more  prolonged  mania. 

Charles  A.,  married,  aet.  34,  cousin  insane. 
First  attack  of  insanity,  following  at  once  on  a 
very  sharp  attack  of  delirium  tremens,  produced  by 
frequent  bouts  of  spirit  drinking.  Besides  drink, 
there  had  been  failure  in  business,  and  nine  months 
before  an  injury  to  the  head.  He  first  became 
suspicious,  believing  the  police  were  after  him ;  he  was 
sleepless,  and  had  bad  dreams.  He  attempted  to  get 
out  of  the  window  ;  he  threatened  to  kill  himself.  He 
had  hallucinations  of  sight,  hearing,  and  taste.  He 
refused  all  food,  and  was  violent  in  his  attempts  to  get 
away  from  those  who  wished  to  injure  him.  He 
accused  his  wife  of  wishing  to  poison  him,  and  he 
threatened  to  injure  her.  On  admission,  he  was 
suffering  from  acute  mania  of  a  very  delirious  type. 
His  face  was  flushed,  his  tongue  and  lips  dry  brown ; 
there  was  yellowness  about  his  conjunctiva;  his  bowels 
were  constipated,  and  his  urine  had  to  be  drawn  off".  He 
was  incoherent,  and  violent  in  his  resistance.  He  had 
to  be  fed  with  the  stomach  pump.  His  bowels  were 
relieved  by  enemata,  and  he  seemed  for  a  day  more 
quiet,  but  he  again  became  violent  and  obstinate. 
For  a  month  he  remained  in  this  condition,  his  state 
being  one  of  extreme  danger.  Constant  artificial 
feeding,  however,  gained  the  day,  and  his  general 
health  and  strength  improved.  His  tongue  became 
clean,  and  his  bowels  more  i-egular.  He  had  halluci- 
nations and  delusions  for  some  weeks  longer,  but  in 
the  end  recovered. 

In  the  next  case,  one  attack  of  mania  following 
drink  was  followed  by  a  period  of  six  years'  health, 
to  be  succeeded  by  a  second  similar  outbreak  due  to 
drink. 


424        Insanity  and  Allied  Neuroses.  [Chap.  xxi. 

A.  W.,  married,  literary  man,  sister  insane, 
father  excitable.  Had  one  short,  sharp  attack  of 
mania,  following  intemperance,  six  years  ago.  He 
recovered,  and  for  some  years  was  teetotal.  The 
present  attack  followed  a  fortniglit's  heavy  drinking 
and  excitement  due  to  successful  speculation.  He  had 
the  most  extravagant  ideas,  and  wrote  and  telegraphed 
to  the  social  and  legal  heads  of  society  ;  hired  and 
•  bought  whatever  he  fancied,  and  behaved  in  a  very  wild 
way.  He  became  more  violent  and  had  to  be  sent  to  an 
asylum,  where  for  a  week  he  was  restless,  noisy, 
violent,  and  destructive.  It  is  hardly  possible  to 
imagine  any  one  more  filthy  than  he  was  during  this 
period.  In  the  end  he  slowly  passed  through  a  time 
of  depression  to  health. 

In  most  similar  cases  discontent  lasts  for  some 
weeks  after  the  mental  improvement  has  commenced. 
In  the  above  cases  we  have  examples  of  mania  of  a 
simple  form  started  by  delirium  tremens  ;  mania  of  a 
severe  delirious  type  having  the  same  origin ;  and, 
lastly,  drink  causing  a  short  attack  of  mania  in  place 
of  delirium  tremens. 

Just  as  drink  acts  often  with  special  efibct  on 
persons  with  insane  inheritance,  so  it  acts  specially 
on  many  who  have  received  injuries  to  the  head.  I 
have  met  with  patients  in  whom  a  very  little  stimu- 
lant would  produce  drunkenness,  and  in  others  I 
have  seen  acute  mania  started  by  stimulants  under 
similar  conditions.  In  a  man  who  had  served 
through  the  China  war,  and  who  had  received  a 
severe  head  injury  from  a  bursting  shell,  very  little 
drink,  even  beer,  produced  drunkenness,  and  this  was 
followed  on  two  occasions  by  violent  maniacal  attacks 
which  lasted  a  week  or  two. 

Under  certain  other  conditions  of  physical  weak- 
ness, alcohol  acts  with  increased  power ;  and  I  believe 
that  I  have  seen  cases  recovering  from  insanity  who 


Chap.  XXL]  Chronic  Alcoholism.  425 

had  less  tolerance  for  stimulants  than  they  had  before 
their  attack  of  nervous  disorder. 

Chronic  alcoholism,  like  acute  alcoholism,  may  pro- 
duce insanity,  or  it  may  be  a  symptom  of  nervous 
disorder.  In  the  former  case  we  shall  find  some  inte- 
resting perversions  of  the  senses,  and  also  tendencies 
to  nervous  deo^eneration  of  one  kind  and  another. 

In  the  latter  we  have  what  has  been  called  dipso 
mania.     With  chronic  alcoholism,  then,  we  may  have 
simple  dementia  of  any  degree,  ranging  from  loss  of 
recent  memory  to  the  obliteration  of  all  but  the  most 
automatic  parts  of  mind. 

Some  forms  of  intoxication  are  supposed  to  act 
differently  from  others  ;  the  easy-going  beer-drinker 
differs  from  the  sentimental  champagne  bibber,  and 
these  again  from  the  desperate,  often  melancholic, 
spirit  taker.  Absinthe  has  different  effects  to  brandy, 
or  else  the  individuals  who  seek  the  various  stimulants 
differ  greatly  among  themselves. 

It  is  said  that  with  absinthe  there  is  a  greater 
tendency  to  convulsive  seizures, 

I  have  no  distinct  proof  that  general  paralysis  is 
due  to  alcoholic  excess  alone,  but  I  believe  that  there 
is  a  cirrhosis  of  brain  as  well  as  of  liver,  and  that  a 
similar  cause  may  start  both. 

Patients  who  have  long  been  in  the  habit  of 
drinking  to  excess  may  become  melancholic,  may  take 
the  pledge,  and  may  give  rise  to  hopes  that  they  are 
reformed.  Chronic  alcoholism  may  be  replaced  by 
chronic  insanity  of  one  kind  or  another. 

Chronic  alcoholism  may  be  slowly  replaced  by  some 
moral  perversion,  so  that  an  apparently  good  wife 
who  has  been  a  secret  drinker  may  take  to  hate  her 
children,  and  maltreat  her  husband  and  the  servants. 
In  such  cases  there  may  be  relapses  into  drunken- 
ness, and  cure  is  very  rare. 

With  all  these  alcoholic  cases  there  may  be  power 


426        Insanity  and  Allied  Neuroses.  [Chap.  xxi. 

to  transact  business,  and  there  is  generally  cunning, 
untruthfulness,  and  malice. 

In  persons  of  neurotic  family,  with  comparatively 
little  alcoholic  excess,  and  in  cases  of  chronic  alcoholism, 
there  are,  as  I  have  said,  special  symptoms  often  pre- 
sent. Suspicion  is  one  of  the  most  common  forms 
of  disorder.  A  man  is  physically  and  mentally  tremu- 
lous from  drink.  He  suspects  persons,  he  is  on  the 
look-out  for  plots  of  all  kinds.  This  insane  suspicion 
grows,  often  slowly,  to  an  extraordinary  extent,  so 
that  at  last  it  is  hard  to  get  out  the  evidence  of 
insanity  because  the  patient  is  so  suspicious  of  every- 
one that  he  will  deny  his  firmest  belief  to  mislead 
those  who  are  questioning  him. 

No  men  are  more  dangerous  than  those  suffering 
from  insanity  with  suspicion.  They  constantly  carry 
weapons,  and  will  not  hesitate  to  use  them. 

Delusions  as  to  plots,  police,  government  malice, 
revenge  by  noble  or  distinguished  persons  to  screen 
themselves,  are  all  common  in  this  malady.  As  an 
extension  of  these  we  have  delusions  as  to  "  follow- 
ing," persecution,  watching,  and  the  like. 

Ideas  of  poisoning  are  very  common,  and  may 
have  a  physical  basis  in  the  chronic  gastritis  of  the 
drinker.  Voices  are  commonly  heard  accusing  the 
patient  or  abusing  and  annoying  him.  If  the  voices 
direct  and  control  the  actions  they  render  the  patient 
highly  dan]-erous.  Visions  may  be  present;  but  peculiar 
sensations  in  the  skin  are  most  noteworthy;  they  are 
described  as  being  like  galvanism.  One  patient  said 
he  felt  like  one  placed  on  an  insulated  stool  having 
shocks  taken  from  him.  Sometimes  the  feelings 
resemble  fine  lines  being  applied  to  the  skin,  a 
"gossamer  feeling,"  as  one  patient  said  to  me.  In 
some  cases  strange  feelings  affect  the  reproductive 
organs,  and  this  may  give  rise  to  false  accusations  and 
to  jealousy.     Jealousy  and  violent  accusations  against 


Chap.  XXI,]  Dipsomania.  427 

liusband  or  wife  are  common  in  chronic  alcoholism, 
and  may  be  dangerous  to  life  or  to  reputation,  the 
consistency  of  the  tales  very  easily  misleading  those 
who  cannot  understand  partial  insanity.  Erotic 
passion  may  show  itself  as  a  symptom  of  alcoholic 
insanity.     Kleptomania  may  also  be  present. 

Insanity  with  violent  jealousy  due  to  drinh. — 
Thomas  S.,  married,  set  25,  maternal  uncle  and 
aunt  insane.  The  patient  had  rheumatic  fever. 
He  slowly  developed  habits  of  intemperance,  and 
squandered  a  large  fortune.  He  had  two  attacks 
of  insanity  of  exactly  similar  character.  He  was 
suspicious ;  he  heard  voices  directing  him.  He 
threw  himself  into  the  river.  He  thought  his  rela- 
tions were  plotting  against  him.  He  refused  food, 
and  fancied  things  were  dirty.  He  accused  people  of 
injuring  him  at  night.  He  told  the  Commissioners 
that  I  had  microphones  applied  to  the  brains  of  the 
patients,  and  so  read  their  thoughts.  He  threatened 
to  kill  me.  He  accused  his  wife  of  misconduct,  and 
said  her  last  child  was  not  his.  He  was  removed  to 
another  asylum  and  for  a  time  improved.  In  the  end, 
with  such  habits,  a  bad  inheritance,  and  a  damaged 
life,  he  will  be  sure  to  have  recurrences,  and  die  in  a 
lunatic  asylum,  if  he  does  not  kill  himself  before. 

Dipsomania  must  be  considered  an  irresistible 
desire  for  stimulants.  It  may  grow  out  of  habit,  it 
may  be  an  inheritance,  it  may  be  an  insane  symptom, 
or  it  may  be  the  vestige  of  an  attack  of  insanity.  It 
occurs  in  men  and  in  women.  It  is  more  common  after 
thirty  than  before ;  but  in  patients  of  insane  inheri- 
tance it  may  be  met  with  at  a  very  early  age.  It  may 
be  a  concealed  vice,  or  it  may  be  a  raging  passion. 
Its  chief  characteristic  is  the  moral  perversion  which 
it  causes.  The  patients,  who  may  be  everything  that 
is  good  and  refined  when  in  health,  become  the  most 
unmitigated  liars  and  the  most  contemptible  cowards 


428        Insanity  and  Allied  Neuroses,  ichap.  xxi. 

and  sneaks.  No  meanness  is  too  low  for  the  dipso- 
maniac, if  it  enable  him  to  get  his  stimulant.  Moral 
perversion,  weakness  of  will,  and  emotional  instability- 
mark  the  disease.  The  prognosis  is  looked  upon  as 
very  unfavourable,  but  I  believe  the  careful  study  of 
these  cases  shows  that  some  are  curable.  If  the 
disease  is  a  symptom  of  other  nervous  or  bodily 
disease  it  may  be  relieved ;  but  if  it  has  slowly 
grown  to  be  a  definite  habit,  nothing  will  cure  it.  If 
neurotic  taint  is  strong,  its  cure  is  not  probable. 

The  efforts  of  the  legislature  and  the  founders  of 
the  Dalrymple  Hetreat  have  done  good  work. 

Chloral  habit — With  every  addition  to  the  Phar- 
macopoeia some  good  may  be  gained,  but  my  experience 
leads  me  to  fear  that  every  new  hypnotic  does  at  least 
as  much  harm  as  good.  In  cliloral  at  first  we  were 
led  to  believe  that  we  had  a  drug  which  neither 
upset  the  digestion  nor  in  any  way  acted  in- 
juriously, giving  a  peaceful  sleep  to  the  weary,  and 
leaving  a  brighter  and  a  better  man.  As  was  to 
be  expected,  this  drug  was  largely  used  in  asylums, 
but  that  it  is  not  all  that  it  was  said  to  be  is  proved 
by  the  steady  way  in  which  its  use  has  dropped  out  of 
the  regular  practice  of  asylums ;  and  in  some  I  should 
almost  as  soon  ask  the  superintendent  if  he  used  re- 
straint as  if  he  used  chloral. 

Chloral  has  its  uses,  to  which  I  shall  refer  later  ; 
but  now  I  have  to  consider  certain  mental  afiections 
produced  by  its  abuse.  It  may  set  up  a  craving  for 
its  use,  much  like  that  for  drink  or  for  opium^  and 
may  give  rise  to  similar  moral  perversion.  I  do  not 
look  upon  the  moral  perversion  solely  from  the  material- 
istic point  of  view,  but  I  also  consider  that  if  there  be 
established  a  very  strong,  or,  as  I  have  put  it,  an  irre- 
sistible craving  for  a  thing,  this  will  over-ride  what  we 
call  moral  laws,  which  are  less  powerful  agents.  The 
diseased  state  is  the  craving,  and  this  varies  in  degree, 


Chap.  XXI.]  Opium-taking.  429 

being  greatest  with  the  most  potent  drugs  or  stimuli. 
I  believe  opium-crave  is  the  greatest,  and  that  for 
chloral  among  the  least,  and  as  a  result  the  moral  per- 
version is  not  quite  so  great  in  the  latter  as  in  the 
former. 

Chloral  will  produce  a  crave,  and  with  this  certain 
moral  defects.  Chloral  will  establish  a  sleepless  habit, 
and  it  will  cause  a  feeling  of  deep  depression,  asso- 
ciated with  anxiety  and  a  hypochondriacal  feeling  at 
the  epigastrium.  It  may  produce  very  great  emotional 
disturbance  and  irritability,  passing  into  deep  melan- 
cholia, with  suicidal  tendencies. 

In  my  experience  it  produces  loss  of  control  and 
tendency  to  impulses,  so  that  suicide  or  homicide  may 
result  in  a  moment  of  loss  of  control.  The  terrible 
feeling  of  depression  described  by  several  patients  who 
have  been  regular  chloral  takers  was  most  marked  on 
awaking  in  the  morning,  when  the  person  felt  as  if  he 
must  precipitate  himself  out  of  the  window.  The  loss 
of  self-control  ends  in  death  from  over-doses  in  the  fol- 
lowing way  :  A  patient  who  used  to  take  a  certain 
dose,  now  takes  it  without  relief ;  he  gets  up  and 
takes  a  little  more,  still  not  losing  consciousness, 
though  in  a  state  of  partial  insensibility  ;  he  then 
takes  an  excessive  dose,  and  sleeps  to  death. 

I  have  seen  stupor  produced  in  one  case  by 
a  single  very  large  dose  of  chloral,  taken  with 
suicidal  intentions,  in  a  woman  who  had  been  leading 
an  irregular  life.  She  in  the  end  got  well,  after  being 
insane  for  nearly  three  years. 

Opium  has  a  most  baneful  eflfect  on  the  minds 
of  those  who  are  in  the  habit  of  constantly  taking  it, 
and  more  recently  the  vice  of  morphia-taking,  or 
rather  of  morphia-injection,  has  become  so  common 
that  the  Germans  speak  of  morphismus  as  well  as 
alcoholismus.  The  chief  effect  of  both  is  to  produce 
the  lust  or  crave  for  the  drug  which  upsets  all  the 


430       Insanity  and  Allied  Neuroses.  [Chap.  xxi. 

moral  character  in  the  way  I  have  already  described, 
the  impulse  being  stronger  than  with  any  other,  and 
the  temporary  exaltation  or  ecstacy  being  still  more 
marked.  The  same  set  of  syniiDtoms,  resembling  deli- 
rium tremens,  may  arise  from  either,  and  it  is  said 
that  if  an  injection  of  morphia  be  given  it  will  quiet 
in  morphismus,  but  that  alcohol  will  cause  excite- 
ment. 

In  this  state  there  is  the  same  tremor,  the  same 
want  of  appetite,  the  same  refusal  of  food,  the  same 
ideas  of  poison,  the  same  hallucinations,  and  I  believe 
the  same  tendency  to  erotic  ideas.  This  state  may  be 
produced  either  by  opium  administered  by  the  mouth, 
or  by  morphia  injections. 

It  may  be  cured,  or  at  least  the  attack  may  be 
got  over,  by  the  total  removal  of  the  drug,  and  this 
may  be  done  suddenly,  though  I  must  add  that  the 
shock  produced  by  the  sudden  withdrawal  is  so  alarm- 
ing that  some  medical  attendant  should  be  handy 
to  supply  stimulants,  and  be  ready  for  the  collapse 
which  will  follow.  Sickness  and  diarrhoea  will  fol- 
low, and  may  cause  alarm,  but  usually  they  pass  in 
the  course  of  a  few  days.  The  diet  should  consist 
of  the  plainest,  most  easily  digested  fluid  food,  and 
some  of  the  meat  extracts  or  peptonised  foods  will  be 
of  service. 

Beside  a  chronic  craving  for  the  drug,  which  over- 
rides all  moral  or  social  laws,  there  may  be  chronic 
morphismus,  with  hallucinations  of  the  same  kind  as 
those  which  are  seen  to  occur  with  alcohol.  I  have 
had  lately  in  Bethlem  two  cases  with  exactly  the  same 
ideas.  Both  were  suspicious,  both  were  pestered  by 
voices  of  friends  and  of  enemies,  and  were  told  to  do 
all  sorts  of  things ;  both  were  much  distressed  on 
account  of  the  supposed  ill-conduct  of  their  friends; 
and  both  had  feelings  of  shocks,  being,  as  they  said, 
galvanised.      These   two    cases    spent    some   time   in 


Chap.  XXI.]  Lead  Poisoning.  431 

comparing  their  various  symptoms,  and  eacli  told  me 
they  were  in  every  respect  similar.  The  patient  with 
the  morphia  habit  got  quite  well,  but  is  subject  to 
relapses. 

Tobacco  has  many  enemies,  and  after  many  battles 
have  been  fought,  it  has  been  shown  that  it  may  pro- 
duce blindness,  associated  with  distinct  changes  in  the 
optic  nerves.  I  never  yet  saw  a  case  of  insanity  due 
simply  to  tobacco.  I  have  seen  aggravation  of  other 
nervous  symptoms  follow  its  use.  I  have  met  with 
nervousness,  indecision,  sleeplessness,  and  jealousy 
depending  on  the  excessive  use  of  tobacco.  It  is  more 
common  to  find  excessive  smoking  first  upsetting  the 
digestive  functions,  and  then  causing  secondarily  ner- 
vous weakness.  Smoking  in  very  young  subjects 
tends  to  indolence  and  self-indulgence,  and  may  thus 
be  a  just  cause  in.  producing  disordered  action  or  loss 
of  control. 

Chronic  chloroform  habit,  with  similar  demorali- 
sation has  been  described,  but  I  have  not  seen  any 
such  cases ;  I  have  seen  all  the  symptoms  of  alcohol- 
ism produced  by  the  excessive  use  of  sal-volatile  in 
one  old  man.  The  habit  was  so  long  established,  that 
half-a-pint  of  this  drug  was  taken  at  a  time.  One 
peculiarity,  too,  of  this  case  was  that  the  patient  con- 
sidered himself  a  model  of  temperance. 

Im^anity  clue  to  lead  poiisoniiig'. — It  is  in- 
teresting to  notice  that  a  certain  series  of  symptoms 
follows  poisoning  by  various  different  substances ;  and 
that  the  symptoms  so  produced  resemble  approxi- 
mately those  which  occur  in  two  very  opposite  dis- 
orders of  the  nervous  system,  hysteria  and  general 
paralysis  of  the  insane.  In  hysteria  we  have  what 
has  been  called  the  mocking-bird  of  nerve  disease  ;  so 
that  every  symptom  which  may  be  the  result  of  disease 
or  destruction  of  the  nervous  system  may  be  repre- 
sented   by    hysteria.     In    general    paralysis    of    the 


432         Insanity  AND  Allied  Neuroses.  [Chap  xxi. 

insane  I  pointed  out  that  an  endless  variety  of 
symptoms  occurs  similar  to  those  found  in  such 
different  diseases  as  epilepsy  and  locomotor  ataxy  ; 
and  with  alcohol  and  lead  similar  symptoms  may 
arise.  It  is  doubtful  whether  some  other  mineral 
poisons  do  not  produce  similar  effects  upon  the 
nervous  system ;  but  here  I  have  only  to  deal  with 
lead.  I  have  seen  acute  mania  following  lead  poison- 
ing, and  passing  off  with  removal  of  the  cause.  In 
one  case  in  Guy's  Hospital,  under  Dr.  Moxon,  a 
woman  had  used  a  lead  lotion  freely,  before  admission, 
to  a  large  open  wound.  This  was  followed  by  acute 
mania  associated  with  a  blue  line  on  the  gums.  Other 
cases  of  acute  mania  have  more  recently  been  observed 
distinctly  connected  with  lead  poisoning.  I  have  seen 
acute  mania  rapidly  followed  by  symptoms  closely  re- 
sembling those  of  general  paralysis,  due  to  the  same 
cause. 

A  man,  aged  thirty-two,  was  admitted  into  Beth- 
lem,  who  had  worked  as  a  clerk  for  some  years  in  a 
lead  manufacturer's  office  ;  great  hesitation  of  speech, 
tremor  of  tongue,  exaltation  of  ideas,  emotional  dis- 
turbance, and  restlessness  were  present.  On  investi- 
gation, the  patient's  friends  said  (although  I  had  found 
a  blue  line  on  his  gums)  that  it  was  impossible  for 
lead  to  be  the  cause  of  his  troubles ;  because,  as  clerk, 
he  had  really  nothing  to  do  with  the  metal ;  but 
believing  the  blue  line  rather  than  the  friends,  I 
treated  him  accordingly,  and  he  recovered,  and  ex- 
plained the  lead  poisoning  by  the  fact  that  depression 
in  trade  had  caused  reduction  of  hands,  and  an 
increase  in  his  duties ;  so  that  not  only  had  he  to  do 
the  correspondence,  but  he  examined  and  sorted  the 
white  lead.  Symptoms  such  as  the  above  are  now 
recognised  as  being  associated  with  lead  poisoning. 
But  Dr.  Bayner  is  convinced  that  the  symptoms  may 
not  only  resemble  those  of  general  paralysis,  but  the  lead 


Chap.  XXI.]  Gout  with  Insanity.  433 

may,  in  fact,  start  the  disease  itself ;  so  that  general 
paralysis  may  arise  definitely  from  lead  poisoning. 
At  all  events,  I  would  say,  from  my  own  experience, 
that  certain  cases^  with  symptoms  of  progressive 
mental  weakness  and  some  loss  of  bodily  power  fol- 
lowing lead  poisoning,  die,  and  in  some  cases  have  fits. 

A  third  condition  of  mental  disorder  associated 
with  lead  is  that  following  epilepsy,  which  has  its 
starting  point  in  lead  poisoning.  There  is  nothing 
special  in  these  cases,  except  that  there  may  be  more 
or  less  pronounced  symptoms  of  paralysis,  such  as  are 
seen  ordinarily  arising  from  lead. 

Oout  with  insanity. — Recently  books  and 
papers  without  number  have  been  written  on  this 
strange  disease,  and  I  feel  that  fashion  in  medicine 
and  the  evidence  of  waves  of  thought  are  nowhere 
better  seen  than  in  relationship  to  this  subject  of  gout 
Twenty -five  years  ago  one  heard  of  gout  as  a  disease 
acquired  by  our  forefathers  and  transmitted  by  them, 
in  a  more  or  less  degenerate  form,  to  us ;  but  now-a- 
days  one  hears  everywhere  of  gout  and  gouty  troubles. 
I  have  no  doubt  that  civilised  people,  especially  those 
belonging  to  the  educated  classes  living  in  cities,  eat 
too  much  stimulating  food  j  that,  in  fact,  they  do 
not  keep  their  sewers  well  flushed,  the  consequence 
being  that  there  are  obstructions  and  overflows 
connected  with  unpleasant  results.  Whether  there  be 
a  special  blood  poisoning  by  uric  acid  or  not,  or 
whether  gouty  conditions  are  dependent  on  defective 
blood  purification  generally,  is  not  for  me  to  consider. 
Some  would  look  to  gout  as  a  nervous  disease  prima- 
rily, but  I  do  not  agree  with  these.  I  have  no  doubt 
that  there  are  cases  of  insanity  connected  directly 
with  gout,  and  I  subjoin  a  case  which  is  as  nearly 
typical  as  could  be  desired,  the  disorder  being  co- 
existent with  and  also  co-extensive  with  gout. 

John   E.,   naval   officer,  married,  set.   53,    had   no 
c  c — 14 


434    Insanity  and  Allied  Neuroses.    [Chap.  xxi. 

insane  blood  relations,  had  been  distressed  by  the  in- 
sanity of  his  wife.  The  symptoms  had  begun  eight  or  nine 
months  before  admission,  and  were  thought  at  first  to 
have  been  the  result  of  his  domestic  worry  and  pecuniary 
difficulties  ;  but  it  was  shown  that  before  the  onset  of 
his  symptoms  he  had  not  had  his  usual  attack  of  gout. 
He  was  a  man  who  lived  well,  but  was  not  intemperate. 
He  became  depressed  and  sleepless  ;  he  refused  food  ; 
and  was  constantly  endeavouring  to  escape  because  he 
believed  he  was  to  be  vivisected.  He  believed  detec- 
tives watched  him,  and  that  he  was  a  centre  of  con- 
spiracy. He  made  five  or  six  determined  attempts  at 
suicide,  and  I  remember  few  patients  who  caused 
more  anxiety  than  did  this  one.  Nothing  seemed  to 
influence  him  for  good,  and  his  whole  thoughts  were 
concentrated  on  escaping  from  the  world  and  his  perse- 
cutions. This  state  continued  till  three  months  after 
his  admission,  it  being  now  a  year  since  the  appear- 
ance of  the  first  symptoms  of  his  insanity.  One 
morning,  going  round  the  wards,  I  was  surprised  to  be 
greeted  by  him  in  a  cheerful  way,  he  pointing  to  his 
foot,  and  with  a  smile  saying,  "Doctor,  I  have  got  the 
gout  again,  and  I  am  all  right."  This  was  true ;  he 
had  a  sharp  attack  of  gout,  was  as  cheerful,  bright,  and 
happy,  as  a  man  could  be,  and  with  the  relief  of  gout 
there  was  no  return  of  insanity  ;  from  that  time  to 
this,  now  some  six  years,  he  has  periodically  visited 
us,  and  always  says,  "  Well,  doctor,  I  have  got  the 
gout,  and  hope  to  keep  it  as  long  as  I  live,  because  my 
mind  is  perfectly  well  and  clear  as  long  as  I  have  it." 
The  prognosis  in  a  case  of  that  kind  must  certainly 
be  doubtful,  for  we  cannot  tell  how  soon  he  may 
again  sufier  from  the  so-called  suppressed  gout. 

Other  writers  have  recognised  the  feeling  of 
terrible  depression  which  is  often  connected  with 
undeveloped  gout ;  and  the  experience  of  most  men 
has  enabled  them  to  witness  the  immense  increase  of 


Chap.  XXI.]        Post-Febrile  Insanity.  435 

irritability  wliicli  may  occur  with  an  acute  attack  of 
gout. 

Attacks  of  acute  mania  have  been  described  as 
depending  on  undeveloped  gout,  and  as  passing  off 
with  the  development  of  acute  gout.  I  have  not  seen 
such  a  case  myself,  though  I  have  met  one  or  two 
gouty  persons  who  have  told  me  that  they  were  most 
buoyant  just  before  an  attack  of  the  gout.  Gouty 
degenerations  of  various  kinds  may  tend  to  ideas  of 
dread,  persecution,  and  to  senile  weak-mindedness,  or 
in  the  end  apoplexy. 

The  treatment  of  insanity  depending  on  gout  must 
be  in  all  respects  similar  to  the  treatment  of  gout ; 
and  I  am  afraid  that  when  asked  how  to  prevent  a 
patient  getting  suppression  of  gout  I  am  unable  to  give 
explicit  advice,  for  the  drinking  of  stimulating  full- 
bodied  wines  is  not  always  sufficient  to  produce  it, 
even  in  predisposed  cases.  As  a  rule,  I  think  exercise, 
so  far  as  you  can  consistently  recommend  it,  Turkish 
baths,  saline  purgatives,  and  change  of  suiTOundings, 
will  be  found  the  most  likely  to  prevent  the  insanity, 
or  to  assist  in  the  removal  of  depression  connected 
with  gout. 

Post-febrile  insanity. — There  are  several  dis- 
tinct conditions  under  which  symptoms  of  mental 
disorder  arise  in  connection  with  febrile  states. 

1.  The  delirium  may  be  replaced  or  immediately 
followed  by  mania ;  this  may  or  may  not  be  associated 
with  extraordinarily  high  temperature. 

I  have  seen  mania  succeed  the  delirium  of  drink, 
the  delirium  of  belladonna,  the  delirium  of  pneumonia, 
and  of  specific  fevers. 

In  these  cases  there  is  generally  well-marked 
neurotic  inheritance  ;  the  patient  passes  through  the 
first  few  days  of  febrile  disturbance  naturally,  then 
becomes  sleepless,  chattering,  and  often  amorous ; 
refusal  of  food  is  very  common,  and  rapid  exhaustion 


436      Insanity  and  Allied  Neuroses.  \.ich2i^.y.y.\. 

follows.  The  mania  may  have  most  of  the  charac- 
teristics of  ordinary  delirium,  but  may  persist  for  days 
or  weeks.  If  sufficient  food  be  given,  the  patient 
generally  recovers,  but  with  refusal  of  food  rapid 
exhaustion  and  death  may  follow.  After  the  mania 
has  lasted  for  a  variable  nurhber  of  weeks,  depression 
or  partial  dementia  is  well  marked,  there  being  some 
vague  dread  or  other  in  the  former  case,  and  in  the 
latter  listlessness,  with  loss  of  memory,  disregard  of 
friends  and  relations,  and  neglect  of  the  decencies  of 
life.  As  soon  as  possible  such  cases  should  be  sent  from 
asylums,  and  change  in  their  surroundings  tried  in 
every  way.  Tonics,  stimulants,  and  abundant  fluid 
foods  are  necessary. 

I  do  not  think  it  matters  whether  the  disturbance 
be  due  to  local  inflammatory  disease,  such  as  pneu- 
monia or  pleurisy,  or  to  rheumatic,  scarlet,  or  typhoid 
fevers 

Besides  the  above  forms  of  mental  disorder,  I  have 
seen  insanity  associated  with  the  outbreak  or  incuba- 
tion of  scarlet  fever  and  small-pox,  and  in  such  cases 
the  early  onset  of  delirium  of  a  marked  kind  has  been 
followed  by  mania,  which  again  has  been  followed  by 
the  specific  rash.  In  several  such  cases  the  acute 
mania  passed  off  with  the  development  of  the  specific 
symptoms  of  the  fever,  but  in  others  the  two  diseases 
were  both  present. 

Fevers  and  feverish  states  may  be  followed  by 
temporary  or  permanent  weakness  of  mind.  It  is  not 
unusual  to  meet  with  cases  of  loss  of  memory  after 
typhoid  fever,  even  when  the  febrile  process  has  not 
been  specially  severe ;  after  rheumatic  fever  there 
may  be  a  similar  loss  of  mental  power. 

Besides  loss  of  memory,  I  have  met  with  cases  of 
moral  and  intellectual  perversion  which  followed 
feverish  diseases. 

In  my  opinion  there  is  no  specific  disease  of  the 


Chap.  XXII.]       Idiocy  and  Imbecility.  437 

brain  due  to  fevers,  but  I  believe  that  either  brain 
wasting  may  result  from  the  rapid  body  wasting  of 
fever,  or,  in  nervous  persons,  the  balance  may  be  dis- 
turbed by  the  all-pervading  febrile  process. 


CHAPTER  XXIL 


IDIOCY    AND    IMBECILITY. 


Causation  of  idiocy — Varieties  of  idiocy  :  genetoiis,  microce- 
phalic, eclampsic,  epileptic,  hydrocephalic,  paralytic,  trau- 
matic, inflammatory — Idiocy  of  deprivation — Cretinism. 

Though  from  a  developmental  point  of  view  this  class 
of  mental  disorders  is  of  very  great  interest,  yet  the 
little  real  good  which  can  be  done  renders  the  care 
and  treatment  of  idiots  an  employment  which  is 
trying  and  unsatisfactory.  In  considering  idiocy,  I 
shall  refer  to  several  classifications  which  have  been 
made,  and  constantly  refer  to  the  most  satisfactory 
book  in  English  on  the  subject,  that  of  Dr.  Ireland. 

Idiots  and  imbeciles  may  be  classified  according  to 
their  facial  types;  and  Dr.  Langdon  Down  has  pointed 
out  that  among  idiots  there  are  to  be  found  those 
having  a  special  negroid  type,  while  others  approach 
the  Mongolian  in  aspect.  Such  a  classification  must 
merely  be  looked  upon  as  provisional.  Other  authors 
have  divided  the  cases  according  to  the  degree  of  their 
mental  acquirements,  and  this  division  is  convenient 
and  natural  in  many  respects.  Thus  there  are  certain 
idiots  who  are  but  automatic  beings,  without  any  evi- 
dences of  the  action  of  the  higher  centres  whatever ; 
and  there  are  others  who,  with  higher  powers,  are 
still  only  able  to  move  about,  and  to  make  use  of  a  few 
words  or  sounds.  A  third  and  still  higher  class  may 
be  able  to  walk  and  talk  a  little,  and  may  be  suscep- 
tible  to  the  influences  of  education  to  some  extent. 


438     Insanity  and  Allied  Neuroses.  [Chap.  xxii. 

Higher  still,  we  may  have  imbeciles  who  are  able  to 
walk  and  talk,  and  acquire  to  a  greater  extent  than  this, 
but  who  are  nevertheless  generally  defective,  and  cannot 
be  looked  upon  as  ordinary  children.  In  this  last 
class  there  may  be  weak-minded  individuals  who  have 
special  aptitudes  (the  so-called  idiot  savant) ;  and  here 
we  may  also  meet  with  moral  imbeciles,  having  mathe- 
matical, musical,  or  mechanical  abilities,  on  the  one 
hand,  or  children  without  moral  sense  on  the  other. 
In  both  these  divisions  there  sometimes  occur  cases  with 
wonderfully  retentive  memories.  Besides  the  above 
groups,  there  are  cases  in  which  the  power  of  develop- 
ment is  not  altogether  arrested,  but  is  greatly  de- 
layed ;  so  that  a  lad  of  sixteen  may  have  the  mental 
capacity  of  a  child  of  six,  and  may  be  capable  of 
indefinite  development  ;  intellectually  such  an  one  is 
always  in  arrears.  In  connection  with  the  above  cases 
have  to  be  considered  cretins,  who,  with  special  phy- 
sical peculiarities,  have  mental  deficiencies  which  may 
be  of  any  of  the  above  types,  and  in  any  degree. 

Idiocy  has  also  been  divided  according  to  its  cause  ; 
for  instance,  the  state  may  have  been  due,  in  the  first 
place^  either  to  congenital  deficiencies,  or  to  some  ac- 
quired fault ;  to  deficiency  of  brain,  or  to  a  deficiency 
of  sense  ;  it  may  have  followed  inflammation  of  the 
brain,  or  resulted  from  convulsions  started  in  teething. 
I  prefer  myself  to  look  at  the  idiot  from  the  more 
widely-considered  pathological  point  of  view ;  and  I 
would  say  that  idiots  may  be  the  result  of  morpho- 
logical or  histological  deficiencies.  Thus  a  child  having 
only  basal  ganglia  can  necessarily  only  be  an  automa- 
ton ;  a  child  with  porencephalus,  having  a  deficiency 
between  the  ganglia  at  the  base  and  the  cortical  layers, 
is  also  necessarily  weak-minded,  there  being  a  want  of 
connection  between  the  receptive  and  the  constructive 
parts  of  the  brain.  In  others,  too,  there  maybe  defi- 
ciencies in  the  commissural  or  combining  fibres,  the 


Chap.  XXII.]     Classification  of  Idiocy.  439 

halves  of  the  brain  existing,  but  there  being  no  power 
of  getting  the  various  parts  into  harmonious  working. 
In  other  cases  there  seems  to  be  arrest  in  the  brain 
cell  development,  the  layers  of  cells  in  cortex  remaining 
in  an  undeveloped  state,  or  only  partially  entering  into 
the  many  relationships  for  which  they  are  intended. 
These  latter  changes  may  be  the  result  of  arterial  alter- 
ation, of  inflammatory  process  such  as  those  following 
injuries;  in  one  special  group  there  is  a  great  overgrowth 
of  connective  tissue  at  the  expense  of  all  higher  tissue. 
Dr  Ireland's  classification  is  : 


1.  Genetous  idiocy. 

2.  Microcephalic  idiocy. 

3.  Eclampsic  idiocy. 

4.  Epileptic  idiocy. 

6.  Hydrocephalic  idiocy. 


6.  Paralytic  idiocy. 

7.  Cretinism. 

8.  Traumatic  idiocy. 

9.  Inflammatory  idiocy. 
10.  Idiocy  of  deprivation. 


There  are  some  general  questions  which  must  be 
referred  to  before  any  special  details  are  entered  upon, 
and  one  of  the  most  important  of  these  is  the  causation. 

I  have  no  doubt  that  inheritance  takes  the  first 
place  in  the  production  of  idiocy ;  but  it  is  an  un- 
doubted fact  that  insane  parents  may  beget  sane  chil- 
dren, and  that  there  are  sane  parents  who  produce 
only  idiotic  imbeciles  or  epileptic  children.  The 
relationships  of  inheritance  are  •difiS.cult  to  understand. 
I  have  seen  several  idiots  whose  mothers  were  insane 
at  the  time  they  were  pregnant  with  them  ;  and  al- 
though I  have  heard  of  cases  in  which  a  fright  during 
pregnancy  has  been  said  to  have  produced  idiocy,  I 
have  myself  no  facts  to  confirm  the  statement. 

Insanity  in  father  or  mother  may  produce  idiocy  in 
son  or  daughter. 

The  insanity  in  the  parent  may  have  been  tempo- 
rary, or  it  may  have  been  chronic  or  incurable,  such 
as  general  paralysis  of  the  insane.  On  several  occa- 
sions I  have  met  with  insane  parents,  whose  insanity 
has    not   shown    itself    for   years    after   the  birth   of 


440     Insanity  and  Allied  Neuroses.  [Chap.  xxii. 

chiidren  who  have  proved  to  be  idiotic.  In  the 
same  families  in  which  one  meets  with  insanity  one 
also  meets  with  idiocy.  Dr.  Ireland  says,  "  idiocy  is, 
of  all  mental  derangements,  the  most  frequently  propa- 
gated by  descent."  Mr.  Lndvig  Dahl  showed  that 
fifty  per  cent,  of  idiots  had  insane  relations.  Dr. 
Langdon  Down  believes  that  if  the  neurosis  be  present 
on  the  mother's  side^  the  first  children  are  most  likely 
to  be  affected  ;  and  if  on  the  father's  side,  it  is  the 
later-born  children  who  will  show  the  weakness. 

One  of  the  most  common  beliefs  in  reference  to 
idiocy  is  that  consanguineous  marriages  are  among  the 
most  common  causes  of  the  production  of  this  condi- 
tion. In  the  popular  mind,  the  marriage  of  cousins 
is  sure  to  produce  idiocy ;  but  I  am  quite  of  the 
opinion  of  Mr.  Huth,  who  most  carefully  studied  the 
whole  question,  that  consanguinity  alone  has  little  to 
do  with  the  production  of  idiots.  If  the  stock  be 
healthy  in  mind  and  body,  there  is  no  extra  risk  in 
the  marriage  of  cousins  ;  the  real  thing  is,  that  when 
near  relations  marry,  any  tendency  to  physical  or 
mental  weakness  is  immensely  increased  ;  and,  there- 
fore, if  two  members  of  a  neurotic  family  marry,  the 
prospect  for  the  offspring  must  be  bad.  Mr.  Huth 
went  so  far  as  to  believe  that,  under  favourable  cir- 
cumstances, consanguineous  marriage  was  rather  bene- 
ficial than  otherwise.  This  I  can  believe  may  appear 
to  be  the  fact;  but  the  chances  are  that  the  greatly  ac- 
centuated diseases  of  the  related  parents  would  cause 
much  mortality  in  the  weaker  members,  only  the  very 
strong  surviving. 

Much  time  has  been  spent,  and  whole  aruiies  of 
statistics  collected,  to  trace  the  origin  of  this  imperfect 
mental  development,  and,  as  a  result,  it  seems  to  me 
that  evidence  has  been  collected  in  sufficient  amount 
to  prove  that  tendencies  to  degeneration  in  one  or  both 
parents,  especially  tendencies  affecting  the  general  or 


Chap.  XXII.]         Causation  OF  Idiocy.  441 

nervous  systems,  are  specially  likely  to  produce  idiocy. 
That  scrofula  seems  in  some  way  to  be  related  to  weak- 
mindedness  is  shown  by  the  number  of  parents  of  such 
patients  who  die  of  consumption,  and  also  by  the 
number  of  idiots  who  suffer  from  some  form  of  scro- 
fulous disease.  What  their  relationship  to  bacilli  is 
I  fail  to  recognise.  As  Dr.  Ireland  says,  most  in- 
fluences which  lower  the  general  health  in  the  parents 
have  been  assigned  as  causes  of  idiocy ;  but,  contrary 
to  what  might  be  expected,  it  does  not  seem  to  be  a 
frequent  consequence  of  hereditary  syphilis.  There  is 
considerable  difference  of  opinion  as  to  the  effects  of 
drunkenness  in  parents  upon  the  production  of  idiocy. 
Some,  including  Dr.  Down,  lay  stress  upon  intoxica- 
tion in  the  father  at  the  time  of  the  conception ;  but  I 
must  confess  that  it  seems  to  me  very  hard  to  prove 
that  the  father  was  in  such  a  state  at  the  time  of  con- 
ception. Drunkenness,  with  its  accompaniments  of 
bad  hygiene  and  enfeebled  physique  in  one  or  both 
parents,  is  certain  to  produce  a  weakly  offspring,  and 
some  such  will  be  sure  to  suffer  from  idiocy.  If  idiocy 
be  the  result  of  degeneracy  in  the  stock,  it  would 
be  likely  that  children  born  from  aged  parents  would 
tend  to  be  less  healthy  than  others,  but  no  special  rela- 
tionship of  aged  parents  to  idiocy  has  been  proved. 

Other  conditions,  at  present  unknown,  tend  to  the 
production  of  idiocy,  and  in  cretinism  one  sees  the 
special  result  of  some  general  condition;  and  in  the 
same  way  idiots  are  met  with  among  the  most  healthy 
and  sober  families.  It  is  a  common  experience  to  find 
a  weak-minded  youth  or  adult  in  any  of  the  out-of-the- 
way  villages  in  England,  France,  or  in  Scandinavia. 
The  very  capacity  which  man  exhibits  for  development 
connotes  a  possibility  for  reversion  to  lower  organic 
and  intellectual  types.  Other  circumstances  have 
been  referred  to  besides  primary  brain  deficiency ; 
thus,  children  born  deficient  in  one  or  more  of  their 


442     Insanity  and  Allied  Neuroses.  [Chap.  xxii. 

senses  run  a  great  risk  of  being  weak-minded  ;  and  a 
superintendent  of  a  large  deaf  and  dumb  institution 
told  me  that  his  chief  difficulty  arose,  not  from  the 
deafness  and  dumbness,  but  from  mental  weakness, 
which  was  always  seen  in  children  of  this  class. 

Oemetoiis  idiocy. — This  term  is  used  to  com- 
prehend all  those  cases,  which,  starting  in  foetal  life, 
cannot  be  traced  to  any  specific  disease.  The  term  is 
convenient,  as  including  a  series  of  cases  not  otherwise 
to  be  collected,  although,  as  the  majority  of  idiots  are 
idiotic  from  birth,  the  term  is  hardly  a  happy  one.  In 
these  cases  morbid  inheritance  plays  an  important  part, 
age  or  decay  in  the  parents  often  existing ;  in  others 
physical  diseases  are  common,  such  as  rickets  and  stru- 
mous disorders ;  the  whole  body  is  feebly  built,  there 
being  torpor,  with  feeble  circulation  ;  the  palate  is  gene- 
rally keel-shaped,  the  molar  teeth  being  closely  approxi- 
mated ;  teeth  are  late  in  appearing,  and  deficient  in 
number.  This  point  of  the  narrowness  and  height  of 
the  vaulted  palate  may  be  of  considerable  importance ; 
for  although  this  kind  of  palate  may  be  present  in 
healthy  individuals  or  in  persons  suffering  from 
ordinary  insanity,  if  it  be  associated  with  weak- 
mindedness  or  moral  peculiarities  in  youth,  I  be- 
lieve one  is  justified  in  saying  that  the  tendency 
to  moral  or  intellectual  deficiency  is  congenital.  The 
teeth  in  idiots  of  this  kind  may  be  worm-eaten  and 
irregular  in  outline,  but  syphilitic  teeth  are  certainly 
not  common.  Such  idiots  are  generally  short,  with 
frequent  occurrence  of  deformities  j  the  ears  are  flat 
or  irregular  in  shape,  of  large  size  ;  hernias  are  also 
present  not  uncommonly  ;  testicles  may  be  present  or 
absent.  These  cases  may  vary  in  degree  very  con- 
siderably, the  worst  cases  being  speechless  automata, 
often  given  to  restless  moving  of  head  and  hands.  Of 
this  group  several  varieties  have  been  pointed  out. 
Dr.  Langdon  Down  and  others  have  marked  a  variety 


Chap.  XXII.]  Cretinoid  Idiots.  443 

closely  resembling  the  Mongolian  type  of  head  and 
face.  Other  racial  types  are  named  from  their 
resemblance  to  the  Grecian,  Ethiopian,  Malayan,  and 
American  Indian. 

An  interesting  group  of  what  might  be  called 
sporadic  idiots  was  described  by  Dr.  Fletcher  Beach 
and  Dr.  Hilton  Fagge  as  cretinoid  idiots ;  they  are 
children  of  low  stature  and  broad  features,  nose  thick, 
mouth  large  and  wide,  hands  and  feet  spade-like;  they 
are  late  in  walking,  and  almost  invariably  imbecile  or 
idiotic  to  a  degree.  The  distinguishing  characteristics 
of  these  children  are  soft  symmetrical  protuberances 
on  each  side  of  the  neck  above  the  clavicles  ;  these  are 
merely  fat  masses.  Some  of  these  cases  are  described 
by  Dr.  Beach  in  the  third  volume  of  the  "  Transactions 
of  the  International  CongTess,"  1881  (p.  626).  It 
suffices  to  say,  that  these  cases  of  apparent  sporadic 
cretinism  are  rare,  but  appear  from  time  to  time  in 
districts  where  neither  goitre  nor  cretinism  occur. 

Genetous  idiots  may  be  educated  to  a  certain  point, 
and  both  Dr.  Down  and  Dr.  Ireland  say  that  a  child 
born  with  defective  intellect  is  more  susceptible  of 
improvement  by  physical  and  intellectual  training, 
than  a  child  who  has  become  idiotic  by  deprivation. 
When  the  idiot's  physical  strength  and  circulation  are 
fair,  the  prospect  is,  of  course,  better  than  when  they 
are  feeble.  There  is  no  special  pathological  condition 
associated  with  the  above  varieties.  Differences  in 
shape  of  skull  and  alterations  in  relationship  of  the 
sphenoid  have  been  described,  besides  want  in  mass 
of  brain  and  imperfect  or  defective  commissural  re- 
lationship. General  measures  are  the  only  ones  likely 
to  be  of  any  service  beyond  special  systems  of  practical 
education.  And  here  one  would  say  that  the  funda- 
mental principles  of  the  education  of  idiots  will  depend 
on  a  simultaneous  appeal  to  several  senses  at  the  same 
time;  so  that  when  an  action  is  desired,  the  suggestion 


444     Insanity  and  Allied  Neuroses,  [chap.  xxii. 

for  it  should  be  made  to  sight,  to  hearing,  and  touch  : 
music  and  drilling  must  always  be  looked  upon  as 
two  of  the  most  important  aids  which  exist  for  the 
development  of  the  weak-minded  of  this  and  other 
descriptions. 

Microceplialic  idiocy. — The  chief  character- 
istic pathologically  in  this  group  of  idiocy  is  the  fact 
of  cerebral  deficiency.  In  some  cases  grotesque  expe- 
riments seem  to  have  been  made  by  nature  to  show 
with  how  small  an  amount  of  brain  the  human  being 
may  exist.  As  a  rule,  the  average  size  of  heads  of 
idiots  is  smaller  than  those  of  healthy  individuals ;  in 
the  class  under  consideration  the  difference  is  great. 
Whatever  may  be  the  general  feeling  as  to  the  re- 
lationship of  size  and  shape  of  head  to  mental  ability  ; 
whatever  view  be  taken  of  the  value  of  phre- 
nology, it  must  be  admitted  that  there  is  a  size  below 
which  any  real  mental  capacity  cannot  be  found  to 
exist.  Dr.  Ireland  says  that  below  seventeen  inches 
in  circumference  the  manifestation  of  intellectual 
power  wi]l  be  feeble,  and  he  gives  the  term  micro- 
cephalic the  limit  of  seventeen  inches.  Some 
parents  have  produced  a  series  of  microcephalic  idiots, 
including  one  case  of  twins.  The  smallness  of  the 
head  may  depend  upon  the  partial  or  general  defi- 
ciency j  the  cerebellum  is  relatively  larger  than  the 
brain.  The  aspect  of  a  typical  microcephale  is  extra- 
ordinary, and  well  seen  in  any  idiot  asylum. 

Microcephalic  idiots  of  an  extreme  degree  are, 
from  time  to  time,  exhibited  by  showmen  as  belonging 
to  some  lost  race,  or  to  a  people  living  on  trees  or 
underground.  Most  of  these  patients  are  short  in 
stature  and  frequently  active  in  movement ;  they  are 
restless,  often  quick  of  perception ;  the  prognosis  will 
depend,  to  a  great  extent,  on  the  size  of  the  skull  at 
birth,  extremely  small-brained  children  developing  little 
either  in  body   or  mind.      These  patients   sometimes 


Chap.  XXII.]        Microcephalic  Idiocy, 


445 


are  supposed  to  resemble  animals,  and  have  been 
described  as  birds,  sheep,  apes,  and  the  like.  In  the 
most  advanced  cases  they  have  no  power  of  feeding 


A  case  of  Sporadic  Cretinism. 


or  protecting  themselves.  If  of  a  slightly  higher  type 
they  may  be  amused  by  trifling  things,  may  have 
strong  tendencies  to  imitation,  and  may  be  able  to  get 
about   and   help   themselves  up  to  a  certain   point  : 


446     Insanity  and  Allied  Neuroses.  [Chap.  xxii. 

fortunately  sexual  power  is  absent,  or  at  all  events 
defective.  It  is  still  an  unsettled  point  as  to  whether 
the  brain  or  the  skull  ceases  to  develop ;  whether  the 
brain  is  restricted  in  its  development  by  the  premature 
ossification  of  the  skull,  or  whether  the  skull  ossifies 
over  a  brain  which  has  ceased  to  develop.  Dr.  Ireland 
thinks  that  the  brain  ceases  to  develop,  and  not  that 
it  is  arrested  by  the  skull.  Yery  little  can  be  done  in 
the  development  of  the  above  cases.  Healthy  sur- 
roundings and  supervision,  with  care  as  to  feeding 
and  warm  clothing,  are  about  the  best  means  of  pro- 
longing life  and  developing  some  little  intelligence. 

eclamptic  idiocy. — Any  serious  disturbance  of 
the  nervous  system  in  early  childhood  has,  as  I  have 
said,  a  tendency  to  arrest  development  or  even  to  de- 
stroy what  has  already  grown.  Any  cause  which  gives 
rise  to  convulsions  in  childhood  may  be  the  cause 
of  idiocy  or  imbecility.  Fortunately  but  few  of  the 
children  who  have  fits  become  idiotic.  Dr.  Shuttle- 
worth  found  that  at  Earlswood  fourteen  per  cent,  of 
the  cases  of  idiocy  were  ascribed  to  teething  con- 
vulsions. Cases  arising  from  convulsions  have  little 
chance  of  improvement.  It  seems  as  if  the  con- 
vulsions had  destroyed  the  power  of  further  develop- 
ment, at  all  events  of  higher  intellectual  development. 
Some  of  these  cases  can  be  trained  to  mechanical  work. 
The  eclampsic  idiot  differs  from  the  next  class,  that  of 

Epileptic  idiocy,  from  the  fact  that  in  the 
former  the  fits  were  but  the  starting  point  of  the 
diseased  process,  and  having  wrought  their  evil,  ceased, 
whereas  in  the  epileptic  patient  the  fits  depend  not 
so  much  upon  a  reflex  irritation,  as  upon  some  organic 
brain  change,  which,  continuing  in  force,  causes  the 
fits  to  be  constant.  Epilepsy,  whether  in  the  form  of 
severe  fits,  or  only  of  slight  losses  of  consciousness, 
may  occur  in  patients  who  are  already  idiotic,  and 
may  in  no  way  be  connected  with  the  production  of 


Chap.  XXII.]  Epileptic  Idiocy.  447 

the   weak-mindedness  ;  both   the   fits  and    the  idiocy 
depending  upon  the  same    pathological    condition    of 


An  Epileptic  Idiot. 


the  brain.  But  the  symptoms  in  the  class  I  am  now 
speaking  of  depend  for  their  causation  upon  the 
recurrence  of  epileptic  fits.     In  speaking  of  epilepsy, 


448     Insanity  and  Allied  Neuroses.  [Chap.  xxii. 

I  have  already  shown  that  in  adults  the  tendency  is 
to  produce  weak-mindedness,  and  it  may  easily  be 
understood  how  disastrous  must  be  the  result  of  re- 
curring fits  occurring  in  the  undeveloped  child.  It 
matters  little,  if  at  all,  what  the  cause  of  the  epilepsy 
may  be,  although  it  is  certain  that  the  tendency  to 
weak-mindedness  is  increased  if  there  be  a  strong 
neurotic  inheritance,  as  the  patient  in  that  case  has 
a  strong  predisposing  cause,  and  an  equally  strong 
exciting  one.  As  I  have  said,  the  frequency  of  the 
fits  and  their  early  development  are  the  two  most 
important  facts  in  this  relationship. 

Epilepsy  occurring  before  seven  years  of  age  is 
certain  to  leave  the  patient  weak-minded.  The  epi- 
leptic idiot  is  said  to  be  the  drollest  inhabitant  of  the 
idiot  asylum.  He  is  often  wild,  untractable,  and  irrit- 
able, many  of  his  symptoms  resembling  the  symptoms 
of  ordinary  insanity.  Some  of  these  cases,  when  the 
fits  are  absent,  appear  as  if  they  were  making  great 
improvement,  but  this  appearance  is  deceptive.  I 
was  consulted  some  little  time  ago  about  a  child  who, 
up  to  seven  or  eight  years  of  age,  had  been  perfectly 
healthy ;  epileptic  fits  of  a  slight  character  appeared 
at  rather  long  intervals;  from  that  time  there  had 
been  an  arrest  in  her  mental  development,  but  there 
was  no  marked  intellectual  degeneration.  As  there 
was  some  bowel  irritation,  I  treated  her  for  worms, 
and  later  with  tonics.  She  recovered  for  a  time,  and 
seemed  to  regain  some  of  her  mental  ability  ;  so  much 
so,  that  I  was  tempted  to  give  a  favourable  prognosis, 
but  the  fits  again  came  on,  her  mind  rapidly  deterio- 
rated, and  she  had  to  be  sent  to  an  asylum. 

This  is  a  very  good  example  of  the  course  which 
such  cases  are  likely  to  take,  giving  some  ground  for 
hope  at  the  time  when  the  fits  are  in  abeyance,  which 
hope  speedily  proves  illusory  when  the  fits  recur.  It  is 
extremely  rare  to  cure  epilepsy,  and  idiocy  dej)endent 


Chap.  XXII.]       Hydrocephalic  Idiocy.  449 

upon  epilej)sy  is  scarcely  more  curable,  althongh  it 
may  well  be  remembered  that  tLie  epileptic  condition  is 
one  depending  upon  so  many  minor  conditions,  that  it 
is  not  to  be  wondered  at  that  epilepsy,  from  time  to 
time,  is  cured  or  outgrown,  and  intellectual  life  started 
afresh ;  hence,  most  writers  on  idiocy  say  that  idiocy 
depending  upon  epilepsy  is  more  curable  than  any 
other  form,  except  that  of  idiocy  due  to  deprivation. 
In  treating  such  cases,  the  invariable  amount  of 
bromide  of  potassium  will  be  given ;  but  I  prefer  to 
follow  the  advice  of  Dr.  West :  "  The  diet  should  be 
mild,  nutritious,  but  usually  stimulating,  and,  as  a 
general  rule,  should  include  meat  comparatively  seldom, 
and  in  small  quantities.  I  have  certainly  seen  epileptic 
fits  increased  in  frequency  and  severity  by  an  abun- 
dant meat  diet,  and  diminished  in  both  respects  when 
a  diet  chiefly  of  milk  and  vegetable  was  adopted." 

Hydrocephalic  idiocy.  —  Hydrocephalus  may 
end  in  death,  may  end  in  mental  recovery,  or  may 
leave  the  child  more  or  less  weak-minded.  The  hydrO' 
cephalus  may  come  on  before  or  after  birth ;  the 
special  cause  of  its  development  is  still  doubtful, 
although  there  seems  to  be  a  distinct  relationship 
between  hydrocephalus  in  the  children  and  the 
physical  degeneracy  in  the  parents,  hydrocephalus 
being  thus  associated  distinctly  with  tubercle.  Hydro- 
cephalic persons  may  be  of  every  shade  of  intellectual 
capacity,  some  growing  up  to  adult  life  and  keeping 
their  reason ;  others  passing  into  dementia  as  the 
result  of  some  acute  mental  disturbance  ;  the  cases  of 
which  I  am  now  speaking  particularly  never  develop 
the  average  mental  capacity.  It  has  been  remarked 
that  hydrocephalic  idiots  may  be  weak  primarily  from 
brain  change,  or  they  may  suffer  chiefly  in  consequence 
of  deprivation  of  one  or  more  of  their  special  senses. 
Blindness  and  deafness  may  occur  in  consequence  of 
hydrocephalus.  The  chief  noticeable  symptom  is  the 
D  D — 14 


45°  INSANI7V  AND  ALLIED  NeU ROSES.   [Chap.  XXII. 

change  in  the  shape  of  the  head,  there  being  a  marked 
enlargement  in  the  frontal  region,  which  extends  right 
round  the  skull.  This  group  of  idiots  provides  most 
of  those  with  really  big  heads.  The  hydrocephalic 
head  resembles  a  ball  in  shape^  the  widest  circum- 
ference  being   often   at  the  temj)les  ;  there    may    be 


Hydrocephalic  Idiot. 

flattening  posteriorally,  and  the  palate  is  said  not  to 
be  vaulted,  but  the  teeth  are  frequently  good.  It  is 
said  that  in  hydroceplialns  the  fontanelle  is  raised ;  in 
rickets  it  is  depressed, 

I  shall  later  refer  to  cases  in  which  the  brain  is 
hypertrophied,  and  in  which  the  skull  also  becomes 
much  enlarged.  A  third  form  of  cranial  enlargement 
which  may  exist  with  idiocy,  is  that  connected  with 


Chap.  XXI T.]       Hydrocephalic  Idiocy. 


45 1 


congenital  syphilis,  and  in  this  case  the  presence  of 
rashes  and  the  peculiarity  of  the  teeth  may  serve  to 
differentiate,  when  taken  with  the  fact  that  the 
syphilitic  skull  is  irregularly  bossed,  not  uniformly 
enlarged.  The  size  of  the  skull  does  not  imply  a  rela- 
tion   between  its    malformation    and  the   amount   of 


'  '  *''''*^"'C^'^'''^  "— '^ 


A  Paralytic  Idiot. 

intellectual  deficiency,  some  hydrocephalics  with  huge 
heads  growing  to  maturity,  and  being  fairly  intellec- 
tual ;  and  even  among  idiots  the  larger-headed  hydro- 
cephalic idiot  is  not  necessarily  more  idiotic  than  one 
less  affected.  Hydrocephalus  may  produce  idiocy 
first,  and  then  a  rapidly  fatal  termination  ;  but  in 
some  cases  there  may  be  an  arrest  of  the  hydroce- 
phalus, wdth  considerable  power  of  intellectual  culture 


452       Insanity  and  Allied  Neuroses.  [Chap.  xxii. 

possible.  Probably  the  chief  danger  in  these  cases  is 
associated  with  their  tubercular  diathesis.  Dr.  Ire- 
land says  they  are,  as  a  rule,  soft,  gentle,  and  trusting 
in  disposition,  although  awkward  in  movement.  With 
the  hydrocephalus  there  may  be  fits,  or  local  paralyses, 
and  then  the  prognosis  becomes  worse.  These  cases 
require  the  treatment  which  would  be  given  to  un- 
healthy children  with  a  tubercular  history.  Cod- 
liver  oil  had  better  be  given  in  one  of  the  many  partly 
digested  forms,  stimulants  with  abundance  of  milk, 
and  for  preference  a  seaside  home  should  be  resorted 
to.  I  believe  strongly  that  good  results  are  pro- 
duced upon  some  of  these  cases  by  the  frequent  ad- 
ministration, in  small  doses,  of  alcohol  in  one  form  oi 
another. 

Paralytic  idiocy. — Iij  every  asylum  there  are 
hemiplegic  or  monoplegic  children,  with  limbs  drawn 
up;  withered,  and  contracted.  The  origin  of  the 
paralysis  may  be  from  some  vascular  lesion  (although 
intracranial  haemorrhages  are  rare  in  children),  to 
some  tubercular  deposit,  or  some  other  growth,  or  as 
the  result  of  want  of  development,  or  inflammation  of 
one  side  of  the  brain.  Injuries  occurring  before, 
during,  or  after  birth,  may  undoubtedly  prevent 
further  development ;  although  one  half  of  the  brain 
may  be  damaged,  it  does  not  follow  that  there  is 
intellectual  deficiency.  Paralysis  may  exist  from 
birth  without  any  marked  arrest  in  mental  growth ; 
but,  on  the  other  hand,  certain  cases,  with  half  of  the 
brain  injured,  neither  develop  in  mind  or  muscle. 

These  cases  have  been  called  paralytic  idiots.  One 
of  the  limbs  may  entirely  cease  to  grow.  A  special 
type  has  been  described  in  which  the  temporal  bone 
on  one  side  has  become  absolutely  flattened  to  such 
an  extent  that  the  one  hemisphere  is  considerably 
less  than  half  the  size  of  the  other.  Such  a  patient 
would    have  a   tottering   gait,   a    stupid    appearance,- 


Chap.  XXII.]  Traumatic  Idiocy.  453 

and  a  dulness  of  perception,  although  some  possibility 
of  intellectual  development  might  exist.  I  would  say 
in  reference  to  these  cases,  that  with  marked  partilysis 
from  bii-th  there  may  be  equally  marked  mental  defi- 
ciency, but  this  is  not  essential.  The  pseudo-hyper- 
trophic  paralysis,  Duchenne  says,  may  be  rarely  asso- 
ciated with  weak-mindedness.  In  the  treatment  of 
paralytic  idiocy,  the  general  and  hygienic  measures 
must,  of  course,  be  tried,  and  it  is  also  necessary  that 
electricity,  galvanism,  friction,  and  passive  movements 
should  be  used  for  the  weakened  limbs. 

Traumatic  idiocy. —  Dr.  Ireland  places  in  this 
group  idiots  who  have  received  some  injury  to  their 
brains  which  may  not  have  left  any  permanent  injury 
apparent,  and  he  would  compare  them  to  those  cases 
of  ordinary  mental  weakness  which  follow  from  so- 
called  concussion.  It  certainly  strikes  one  that  it  is 
not  uncommon  to  meet  with  cases  in  whom  a  shock, 
physical  or  moral,  seems  sufficient  to  change  the  whole 
vital  relationships  of  the  individual,  so  that  from  that 
time  he  is  either  a  changed  being,  or  one  with  definite 
tendencies  to  degeneration.  Injuries,  it  is  said,  with- 
out producing  signs  of  inflammation,  may  cause  weak- 
mindedness,  or  inability  for  development  in  children. 
It  seems  to  me  that  it  is  the  sudden  injury  which  does 
the  harm,  and  that  comparatively  little  injury  appears 
to  have  been  produced  by  the  mutilations  which 
fashion  in  the  shape  of  heads  has  so  frequently  caused 
among  savage  races.  It  seems  strange  that,  if  sudden 
shocks  to  the  brain  should  produce  idiocy,  more  chil- 
dren are  not  born  fools.  According  to  some,  the 
right  of  primogeniture  rests  upon  the  danger  which 
a  first-born  son  has  to  run  at  his  birth. 

Statistics  still  leave  it  uncertain  as  to  the  relative 
number  of  first-born  children  that  become  idiotic ; 
but  the  evidence  seems  to  me  to  point  slightly  in 
favour  of  the  belief  that  there  is  greater  danger  to 


454       Insanity  and  Allied  Neuroses.  [Chap.  xxri. 

first-born  children,  especially  if  tliey  are  males.  Idiocy 
does  not  seem  to  follow  unduly  on  instrumental 
labours.  It  seems  certain  that  injuries  before  or 
after  birth  may  cause  idiocy  ;  but  that  injuries  occur- 
ring later,  in  the  first  few  years  of  childhood,  are  still 
more  dangerous  than  intra-uterine  injuries.  The 
prognosis  depends  very  much  upon  the  general  physical 
development.  Most  of  these  cases  are  said  to  belong 
rather  to  the  imbecile  than  the  idiotic  ty]oe. 

Inflamma-tory  idiocy.  —  Inflammation  and 
arrest  of  development  may  follow  on  injury ;  but  this 
special  class  is  intended  to  include  those  in  whom 
inflammations  of  the  nose  and  ears,  which  are  asso- 
ciated at  times  with  contagious  fevers,  may  spread  to 
the  brain  membranes.  Such  lesions,  as  a  rule,  prove 
fatal ;  and  although  parents  are  apt  to  consider  idiocy 
as  a  consequence  of  fever,  it  is  probably  more  often 
the  fact  that  the  weakness  which  had  existed  all 
along  was  not  noticed  till  at  the  age  when  these  fevers 
commonly  occur. 

Inflammation  of  the  brain  or  its  membranes  un- 
doubtedly may  occur  before  birth,  in  which  cases  the 
causation  of  the  disease  is  not  cleared  up  till  after 
death.  As  might  be  expected,  the  grades  of  idiocy 
from  this  cause  vary  considerably. 

Under  the  head  of  inflammatory  idiocy  is  considered 
that  of  hypertrophic  idiocy.  In  this  branch,  of  which 
I  have  seen  several  cases  under  the  care  of  Dr.  Beach, 
the  skull  is  usually  much  enlarged,  the  enlargement  is 
more  general  than  in  hydrocephalus.  No  known  cause 
has  been  discovered  for  this  aflfection.  There  may  be 
great  increase  in  size  of  brain  without  any  marked 
idiocy  on  the  one  hand,  or  without  intellectual  in- 
crease on  the  other.  Some  of  the  children  have  been 
described  in  whom  precocity  existed.  Most  of  the 
cases  die  early,  some  with  paralytic  symptoms,  with 
or  without  fits.      The  distinctive  diagnosis  rests  upon 


Chap.  XXII.]       Idiocy  of  Deprivation. 


455 


the  observation  that  in  hydrocephalus  the  increase  is 
most  prominent  at  the  temples,  and  in  hypeii:rophy  it 
is  most  prominent  above  the  superciliary  ridges.  In 
hydrocephalus  the  width  between  the  eyes  is  increased. 
In  Dr.  Beach's  second  case  the  prominences  above  the 
superciliary  ridges  were  well  marked ;  the  brain 
was  very  heavy,  it  weighed  62  ounces.  Connective 
tissue    increase    seems    to    be    the    chief     histological 


A  Hypertroph.ic  Imbecile. 

change  in  these  cases,  and  the  mental  symptoms  ap- 
pear to  be  due  to  the  gradual  suppression  of  intellec- 
tual function  caused  by  pressure.  When  the  calvarium 
has  been  removed  the  brain  behaves  post  mortem  as 
if  it  had  been  subjected  to  immense  pressure,  and  it 
is  impossible  to  replace  the  skull-cap.  Such  a  con- 
dition is  practically  hopeless. 

Idiocy  of  deprivati«ftn. — I  have  already  re- 
ferred to  the  effect  of  sense  deprivation,  and  this 
class  includes  those  in  whom  mental  development  was 


456       Insanity  and  Allied  Neuroses.  [Chap.  xxir. 

defective  in  consequence  of  the  gateways  to  know- 
ledge being  closed.  Dr.  Ireland  properly  says,  idiocy 
by  deprivation  is  like  a  seed  which  does  not  s^^rout 
because  it  is  kept  away  from  sunlight  and  moonshine  j 
while  incurable  idiocy  is  like  a  seed  in  which  the  ger- 
minal faculty  has  been  destroyed.  In  connection  with 
this  group,  the  ever-memorable  case  of  Laura  Bridg- 
man,  in  whom  all  the  senses  but  that  of  touch  were  de- 
stroyed, is  to  be  remembered."^  This  case  shows  clearly 
how,  with  sufficient  time  and  pains,  the  deficiencies 
due  to  degeneration  of  one  sense  can  be  made  up  by 
the  training  of  others ;  and  the  important  considera- 
tion is  this,  that  idiots  who  are  idiotic  or  imbecile 
from  want  of  one  or  more  senses  may  be  developed  to 
a  very  considerable  extent  if  treated  sufficiently  early. 
If  such  children  have  been  allowed  to  run  wild  till 
they  are  twelve  or  thirteen  years  old,  it  is  extremely 
difficult  to  do  much  for  them.  Early  methodical 
training  is  the  only  thing  to  look  to. 

Cretmism. — Associated  with  all  the  natural 
beauties  of  mountain  scenery  one  meets  with  the  most 
deplorable  class  of  idiots  called  cretins.  The  causa- 
tion of  their  condition  is  still  doubtful,  although  it  has 
been  observed  and  studied  by  many  able  observers. 
A  definite  relationship  exists  between  cretinism  and 
goitre,  and  there  seems  to  be  some  relationship  be- 
tween limestone  districts  and  the  presence  of  goitre. 
Wherever  goitre  exists  limestone  seems  to  be  present, 
and  where  goitre  has  had  its  home  for  generations 
cretinism  is  common.  In  England,  in  several  districts, 
goitre  is  conunon  enough ;  but  my  personal  experience 
of  some  parts  of  Cumberland,  where  I  saw  hundreds 
of  goitrous  people  with  families,  led  me  to  believe  that 
something  was  wanting  in  England  for  the  full  de- 
velopment of  cretinism.  Although  one  or  two  cretins 
existed  in  the  district  I  refer  to,  such  cases  were  very 
*  See  "Journal  of  Mental  Science,"  vol.  xxi.,  p.  893. 


Chap.  XXII.]  Cretinism.  457 

rare.  The  aspect  of  the  cretin,  especially  with  the 
large  goitre,  is  characteristic  ;  a  iiat  broad  face,  thick 
lips,  and  a  large  mouth,  a  flat  nose,  with  depressed 
root,  and  slanting  eyes,  big  expanding  ears,  the  w^hole 
carried  by  a  squat  dwarfish  creature  with  a  sallow  un- 
healthy complexion.  In  these  cases  the  facial  aspect 
has  been  traced  to  the  sphenoids,  and  the  premature 
ossifications  of  the  base  of  the  skull  have  been  looked 
to  as  the  cause  of  the  condition.  And  it  is  interesting 
to  remark,  that  in  one  case  of  cretinoid  degeneration 
in  a  woman  (myxoedema)  which  I  had  in  Bethlem, 
there  was  great  overgrowth  of  bone,  with  exostoses  all 
over  the  alse  of  the  sphenoids.  So  much  for  the  causal 
relations  of  cretinism.  It  is  found  in  Sardinia, 
France,  Austria,  Switzerland,  and  the  Pyrenees.  It  is 
met  with  also  among  the  Andes,  and  the  Himalayas. 
It  occurs  in  China,  Sumatra,  the  Rocky  Mountains  of 
America,  and  in  Madagascar.  The  condition  is  not 
necessarily  hereditary ;  but  it  is  noteworthy  that 
cretinous  or  goitrous  parents  may  produce  cretins 
among  their  native  mountains,  but  the  same  parents 
may  produce  healthy  children  in  other  districts. 

Every  variety  of  weak-mindedness  may  occur  with 
cretinism.  In  some,  only  the  slightest  moral  or  intel- 
lectual defects  owe  their  origin  to  this  condition, 
whereas  in  others  complete  absence  of  mind  or  power  of 
mental  development  is  due  to  this  cause.  Some  children 
are  met  with  who  from  birth  have  irregularly-shaped 
heads.  They  have  the  conformation  of  features  I  have 
described,  and  although  generally  the  child  develops 
slowly,  cases  may  occur  in  which  physical  development 
is  fair.  The  appetite  is  often  ravenous  ;  they  eat 
much  and  sleep  much  ;  they  are  placid  and  expression- 
less. The  abdomen  is  round  and  tub-like,  limbs 
small  and  feeble,  teeth  are  generally  irregular  and 
scattered,  speech  may  be,  and  often  is,  slow  in  develop- 
ment, and  stammering  when  it  does  come.     Symptoms 


458       Insanity  and  Allied  Neuroses.  [Chap.  xxii. 

generally  appear  before  the  fourth  year,  and  rarely 
come  on  after  the  seventh.  There  are  more  mc^e  than 
female  cretins.  Hearing  seems  to  be  more  defective 
than  seeing  ;  taste  and  smell  are  often  deficient,  and 
feeling,  if  not  dull,  is  often  confused  and  with  false 
impressions.  Intellectually  there  is  eveiy  degree  of 
obtuseness,  so  that  in  the  lowest  or  full  cretins  the 
life  led  is  a  purely  negative  one ;  as  we  get  higher, 
speech  and  desire  may  be  present  in  rudimentary  states, 
and  in  the  highest  cretins  we  meet  with  little  beyond 
imbecility,  with  more  or  less  moral  deficiency.  With 
all  the  above  conditions  may  be  associated  complica- 
tions such  as  epileptic  fits,  tubercular  tendencies.  The 
prognosis  of  the  case  will  be  rendered  more  difficult, 
and  the  hope  of  relief  will  be  reduced,  if  any  such  com- 
plications exist.  The  one  treatment  is  the  early 
removal  from  the  dangerous  neighbourhood.  The 
mother  of  a  cretin  should  be  removed  from  the  neigh- 
bourhood. When  a  mother  of  one  cretin  is  pregnant 
she  should  be  removed,  and  no  second  child  should  be 
allowed  to  be  born  where  the  danger  exists.  In  any 
case,  great  good  may  be  done  by  change  of  drinking- 
water,  change  of  surroundings,  associated  with  healthy 
nutritious  food.  Iodine  alone  has  been  tried  and 
has  failed,  iron  in  one  shape  or  another  being  much 
more  useful. 

In  these  cases,  as  in  most  others  of  mental  weak- 
ness, regulated  gymnastics  and  drilling  are  useful 
additions  to  the  treatment. 

There  are  a  few  more  special  points  to  which  one 
may  refer  before  leaving  the  subject  of  idiocy.  For 
any  special  study  of  idiots  one  must  not  only  take  in 
detail  the  deficiencies  which  may  possibly  exist  asso- 
ciated with  weak-mindedness,  but  consider  also  the 
shades  and  degrees  of  these  complications,  and  also 
notice  the  secondary  results  following  in  the  course  of 
the  development  of  children  of  weak  mind.     As  I  have 


Chap.  XXII.]        Idiocy  and  Imbecility.  459 

said  before,  in  cases  of  nervous  disorder  or  deficiency 
the  whole  bodj  sulGfers.  In  the  great  majority  of  cases 
the  aspect  of  the  idiot  is  repulsive ;  the  stature  is 
short ;  the  habits  inhuman  ;  there  being  in  one  case 
a  neglect  of  personal  cleanliness,  and  in  another  un- 
controlled appetites.  Idiots  unfortunately  frequently 
beget  or  bear  children,  such  children  being  all  but  cer- 
tainly idiotic.  Besides,  v^hat  has  been  described  as 
acute  mental  disturbance  may  occur  in  children  whose 
nervous  systems  are  not  sufficiently  stable  to  recover 
from  these  attacks.  Mania  I  have  referred  to  as  oc- 
curring in  early  childhood,  and  resulting  in  weak- 
mindedness.  Melancholia,  too,  with  suicidal  tendencies, 
has  been  referred  to  under  similar  circumstances;  it 
must  be  remembered  that  among  idiots  there  may  be 
corresponding  nervous  disturbances,  so  that  maniacal 
outbreaks  or  melancholic  attacks  may  occur  in  these 
patients.  The  child  who  has  attacks  of  mania,  being 
idiotic,  may  again  become  quiet  and  tractable,  only  per- 
haps to  have  recurrent  outbreaks  of  mental  disorder.  In 
every  idiot  asylum  there  are  some  specially  bad  children 
who  seem  to  correspond  to  the  cases  of  chronic  mania 
in  ordinary  asylums;  such  patients  are  not  only  very 
troublesome,  but  are  not  likely  to  improve.  To  sum 
up  :  idiocy  and  imbecility  are  but  degrees  of  weak- 
mindedness,  in  which  one  or  more  of  the  factors  of 
mind  are  partly  or  wholly  undeveloped  ;  the  condition 
may  depend  upon  changes  occurring  before  or  after 
birth,  and  are  largely  dependent  upon  nervous  inhe- 
ritance. These  cases  are  only  partly  curable ;  the 
most  that  can  be  done  with  a  great  majority  being  to 
try  to  render  them  less  repulsive  than  they  have  been, 
and  to  teach  them  some  mechanical  arts.  For  such 
treatment  special  training  is  required. 


460 
CHAPTER  XXIII. 

RESPONSIBILITY    OF    LUNATICS. 

Responsibility — Testamentary  capacity,  and  other  practical  and 
social  matters  connected  with  insanity. 

I  CANNOT,  within  the  scope  of  this  work,  pretend  to 
enter  upon  any  discussion  as  to  the  actual  and  definite 
legal  responsibility  of  persons  of  unsound  mind,  as 
such  a  discussion  would  necessitate  a  full  exposition 
of  the  foundations  of  the  criminal  law  in  England,  and 
the  application  of  its  principles  to  the  technique  of 
insanity,  together  with  a  copious  reference  to  cases 
which  have  arisen  in  respect  of  such  application. 

The  medical  and  legal  professions  have  always  been 
somewhat  at  variance  upon  this  head  ;  the  difference  of 
opinion  has  doubtless  arisen  from  the  difference  of 
motive  on  either  side.  The  physician,  looking  upon  his 
patient  as  an  individual  to  be  cured,  is  tempted  to 
extend  the  boundaries  of  disease,  and  waives  the  ques- 
tion of  responsibility  altogether ;  the  lawyer,  whose 
business  it  is  to  define  that  which  has  to  be  condemned, 
is  impelled  to  narrow  them,  and  search  for  points  of  re- 
semblance between  the  terra  incognita  of  mental  per- 
version and  the  lines  he  has  already  laid  down.  A  too 
free  extension  of  either  view  is  equally  undesirable,  and 
the  physician  must  on  his  part  be  willing  to  admit 
that  a  system  of  laisser-faire,  and  indiscriminate 
exoneration  from  all  blame,  is  out  of  harmony  with 
both  the  experience  and  expressed  motives  and  wishes 
of  the  human  race,  and  is  to  be  avoided  in  practice. 
Experience  teaches  us  to  look  upon  evil  as  a  necessity, 
and  when  we  have  done  this  we  seek  for  the  best 
possible  arrangement  of  that  which  we  cannot  avoid. 
Thus  we  have  the  foundation  of  the  criminal  law  in 
its  relationship  to  morals  ;  and  as  it  is  endorsed  by  the 
conseTisus  of  public  opinion,  it  behoves  the  physician, 


Chap.  XXIII.]  Responsibility.  461 

as  a  unit  of  the  social  mass,  to  conform  to  it,  and  to 
furnish  such  facts  and  experiences  as  he  may  deem 
likely  to  facilitate  and  clarify  its  procedure.  The 
question  of  responsibility  is  in  truth  not  a  medical 
question  at  all.  It  may  be  a  question  either  of  philo- 
sophy, of  law,  or  of  common  sense.  But  neither  the 
philosopher,  the  lawyer,  nor  the  ordinary  individual, 
when  they  have  to  deal  with  cases  of  unsound  mind, 
can  move  a  step  without  a  knowledge  of  the  necessary 
facts.  These  are  the  province  of  the  physician,  and  if 
he  himself  does  not  undertake  to  discuss  the  question 
of  legal  or  philosophical  responsibility  from  the  wider 
point  of  view,  it  is  nevertheless  desirable  that  he 
should  supply  such  materials  toward  the  ultimate 
building  of  the  edifice  as  are  the  result  of  his  own 
experience ;  and  in  cases  of  responsibility  having  to 
do  with  the  ordinary  social  relationships  of  persons  of 
unsound  mind,  he  is  from  the  nature  of  his  position 
singularly  capable  of  pronouncing  a  just  opinion  and 
proffering  advice  to  others. 

As  to  the  law  (which  is  chiefly  "judge-made,"  or 
depends  upon  the  replies  given  by  the  judges  to  the 
questions  proposed  by  the  House  of  Lords  in  the  case 
of  McNaughten,  occurring  in  1843),  it  is  now,  I 
think,  a  matter  of  general  opinion  that  it  requires 
considerable  modification.  I  cannot  but  think  that 
the  time  may  shortly  arrive  when  physicians  will  take 
upon  themselves  to  furnish  a  consensus  of  opinion  as 
to  the  lines  upon  which  it  should  be  re-modified,  so  as 
to  benefit  by  the  important  results  of  recent  scientific 
and  medical  research.  The  broad  and  sweeping  pro- 
visions of  the  law  cannot  with  justice  be  applied  to 
insanity  as  a  whole,  but  there  must  be  given  such 
data  as  will  serve  to  classify  the  variable  will-afiec- 
tions  to  which  persons  of  unsound  mind  are  liable  ; 
and  the  manner  in  which  such,  as  far  as  they  are 
owing  to  disease,  may  assist  in  producing  crime. 


462      Insanity  amj  allied  Neuroses.  [Chap,  xxiii. 

One  of  the  difficulties  which  has  arisen  has  been 
that  lawyers  have  definitely  demanded  precise  lines 
of  demarcation  to  be  drawn  between  sanity  and  in- 
sanity; and  also  between  conditions  in  which  pun- 
ishment should  be  administered,  and  conditions  in 
which  the  person  must  be  looked  upon  as  irrespon- 
sible. Specialists  know  from  experience  that  there 
are  persons  dwelling,  as  Dr.  Maudsley  would  say, 
on  the  borderland  of  crime  and  insanity,  who  may 
at  one  time  be  more  insane  and  less  criminal,  and 
at  another  more  criminal  and  less  insane.  That,  in 
fact,  sometimes  they  merit  punishment,  and  at  others 
may  require  treatment.  Just  as  we  have  seen  that 
there  is  no  clear  distinction  between  sanity  and  in- 
sanity, so  we  must  admit  that  there  is  no  possibility  of 
drawing  by  definition  any  clear  distinction  between 
liability  for  acts  done,  and  irresponsibility.  There- 
fore it  is  necessary  that  the  provisions  of  the  criminal 
law  should  be  clearly  defined  and  categorically  stated 
with  respect  to  all  the  main  circumstances  of  the  case. 

One  of  the  main  standpoints  of  the  law  hitherto 
has  been  to  administer  justice  upon  the  supposition 
that  delusions  are  essential  in  lunacy.  Another  has 
been  to  enquire  whether  the  lunatic  was  capable  of  dis- 
tinguishing between  right  and  wrong  at  the  time  of 
the  act.  Both  these  principles,  although  they  might 
be  made  use  of  as  useful  aids  to  any  enquiry,  are 
radically  defective,  inasmuch  as  they  exclude  from 
consideration  the  most  important  medical  evidence ; 
that  is,  the  most  important  facts  of  the  case.  A 
delusion,  as  the  physician  well  knows,  is  never  the 
expression  of  the  whole  of  the  disordered  motives 
which  directly  or  indirectly  aflfect  the  causation  of  the 
act.  And  those  who  are  most  of  all  conscious  of 
the  difference  between  right  and  wrong  are  often 
those  who  suffer  from  the  strongest  infiuences  of  dis- 
ease which  overrule  their  knowledge.      Again,   it  is 


Chap.  XXIII.]  Crime  and  Loss  of  Control.         463 

highly  unjust  to  say  that  because  a  person  does 
not  appear  to  have  a  delusion  as  the  foundation  for 
his  act  that  he  must  be  held  responsible.  It  is 
not  necessary  to  have  a  delusion  to  annul  responsi- 
bility. A  person  may  in  acute  mania  kill  another  in 
the  mere  buoyant  exercise  of  his  feelings  of  strength ; 
and  although  he  may  have  delusions,  the  loss  of  self- 
control  and  not  the  delusions  was  the  cause  of  the 
accident.  This  loss  of  self-control  is  one  of  the  most 
difficult  points  to  be  established  as  a  symptom  of 
mental  disease.  It  is  admitted  that  the  epileptic  may 
commit  a  crime,  being  unable  to  control  himself,  his 
mind  being  in  much  the  same  condition  in  which 
his  body  is  when  seized  by  epileptic  convul- 
sions, and  quite  beyond  his  control.  Other  con- 
ditions may  give  rise  to  acts  which  are  uncontrolled, 
and  which  no  ordinary  amount  of  pressure  or  change 
of  surroundings  would  enable  the  person  to  control ; 
and  here  arises  the  difficult  and  complicated  question, 
Under  what  conditions  is  this  loss  of  self-control  a 
symptom  of  mental  disease,  and  under  what  conditions 
is  it  to  be  looked  upon  as  the  result  of  conditions 
which  might  and  ought  to  have  been  checked  by  the 
patient  %  In  some  circumstances,  the  temporary  loss 
of  control  is  due  to  self-indulgence  in  the  individual ; 
and  then  rightly  the  person  is  considered  to  be  re- 
sponsible for  having  knowingly  allowed  himself  to  get 
into  a  position  in  which  he  would  become  unable  to 
restrain  himself.  But  even  this  is  a  dangerous  prin- 
ciple to  admit,  for  it  is  easy  to  see  that  a  very  slight 
dereliction  on  the  part  of  the  individual  might  lead  to 
an  extremely  difficult  position. 

And,  again,  there  can  be  no  doubt  that  a  vast 
number  of  cases  may  arise  in  which  the  insanity  of 
the  patient  and  the  impulses  from  which  he  has 
suffered  in  consequence  of  nervous  disease,  if  not  suffi- 
cient to  exculpate  him  from  blame  altogether,  ought 


464     Insanity  and  Allied  Neuroses.  [Chap,  xxiii. 

nevertheless  to  be  alleged  as  strong  condonation  of  his 
offence.  The  physician  claims  as  a  general  principle, 
that  an  insane  person,  whatever  his  delusions  or  other 
mental  symptoms  may  be,  must  be  considered  alto- 
gether irresponsible  for  any  criminal  act  he  may 
commit ;  and  I  think  the  tendency  of  legal  reform 
should  be  to  make  full  allowance  for  the  influences  of 
disease  upon  conduct. 

Criminal  acts  may  arise  from  delusions  of  one  kind 
and  another,  from  hallucinations  of  the  various  senses, 
from  loss  of  control,  which  may  act  in  various 
different  ways;  the  most  difficult  point  of  all  to  de- 
cide upon  is  the  so-called  impulsive  insanity,  in 
which  a  patient  loses  self-control,  and  commits  an 
act,  the  details  of  which  he  remembers,  but  which 
he  truthfully  says  he  was  unable  to  prevent.  Such 
insane  impulses  undoubtedly  do  occur,  and  I  have 
been  consulted  by  patients  who  have  told  me  that 
loss  of  control  of  this  kind  would  come  upon  them 
like  a  storm,  and  that  they  would  seek  shelter  any- 
where to  avoid  the  danger  which  might  arise  to  them- 
selves or  others.  It  is  simple  enough  when  these 
impulses  occur  in  persons  who  have  suffered  from 
mental  unsoundness,  but  it  is  much  more  difficult 
when  the  only  evidence  of  insanity  is  the  existence  of 
these  impulses ;  for  it  may  be  said  that  they  are  but 
the  result  of  uncontrolled  pleasure  of  power,  which  is 
common  to  all.  I  should  hesitate  before  accepting 
impulse,  unless  I  had  evidences  of  insanity  in  other 
members  of  the  family,  or  neuroses  such  as  neuralgia 
or  epilepsy  in  the  patient  himself. 

Having  offered  these  general  remarks  upon  the 
subject,  I  will  now  confine  myself  to  some  specific 
details,  all  of  which  will,  I  think,  furnish  evidence  of 
the  extreme  difficulty  that  exists  in  making  any  broad 
distinction  between  responsibility  and  irresponsibility 
in  individual  cases. 


Chnp.  XXIII.]    Alcoholic  Intoxication.  465 

I  may  first,  however,  remark  tliat  it  must  be  ad- 
mitted that  in  the  great  majority  of  cases  of  insanity, 
ordinary  motives  appeal  to  the  person  of  unsound  mind 
in  a  way  precisely  similar  to  that  in  which  they  affect 
the  sane.  There  are  patients  in  asylums  who  can  be 
guided  by  anticipated  pleasure,  or  by  threatened  de- 
privation of  enjoyments,  and  therefore  who  must  be 
looked  upon  as  so  far  controllable  if  not  responsible. 
A  patient  is  frequently  told  that  if  he  will  control 
himself  for  so  many  days  he  shall  see  his  relations ; 
or,  on  the  other  hand,  he  may  be  told  that  with  self- 
control  will  come  liberty  of  spending  a  day  away 
from  the  asylum.  In  fact,  in  this  way  alone  hospitals 
and  asylums  can  be  managed  for  the  benefit  of  the 
patient.  But,  although  managed  in  this  way,  it  does 
not  necessarily  follow  that  the  extension  of  the  belief 
in  power  of  self-control  is  justifiable  when  a  crime 
has  been  committed ;  there  are  certain  classes  of 
patients  who  at  once  must  be  recognised  as  likely  to 
commit  crimes  against  society  if  at  large,  without 
there  being  any  idea  whatever  that  they  can  be  con- 
sidered as  responsible.  Some  of  the  specific  details  to 
which  I  shall  now  refer  will  afford  an  illustration  of 
this. 

The  subject  of  alcoholic  intoxication  is  one 
which  presents  many  difiiculties.  A  person,  say, 
is  given  powerful  stimulants,  masked  or  concealed  in 
some  way  ;  or  being  weak,  or  suffering  from  an  old 
injury  to  the  head,  an  amount  which  formerly  would 
not  have  affected  him  now  produces  a  great  effect ; 
in  a  state  of  acute  alcoholism  he  commits  a  crime, 
and  doubtless  would  be  considered  not  guilty  ;  but 
if  he  has  experienced  several  times  the  danger 
which  he  incurs  by  taking  stimulants  even  in 
small  quantities,  and  yet  continues  to  indulge,  and 
then  perpetrates  a  crime,  he  may  justly  be  considered 
responsible,  even  although  it  may  be  proved  that  by 

E  E — 14 


466     Insanity  and  Allied  Neuroses.  [Chap,  xxiii. 

inheritance,  or  in  consequence  of  injury  to  the  head,  he 
is  especially  liable  to  be  afiected  by  stimulants.  Next, 
if,  in  consequence  of  intemperance,  he  becomes  slowly 
affected  by  mental  disorder,  and  in  a  state  of  delirium 
tremens  he  commits  a  crime,  he  will  probably  not  be 
considered  fuPly  responsible.  If,  instead  of  delirium 
tremens,  alcohol  produces  chronic  insanity  or  general 
paralysis  of  the  insane,  and  in  this  condition  of 
genuine  insanity  he  does  harm,  he  will  not  be  con- 
sidered responsible  for  his  acts.  Thus  it  will  be  seen, 
from  the  above  example,  how  complicated  are  the  rela- 
tionships between  responsibility  and  irresponsibility. 

Theft  may  be  a  sign  of  mental  disorder.  The  general 
paralytic  who  believes  himself  immensely  wealthy, 
and  who  thinks  that  the  whole  world  is  his,  can  hardly 
be  blamed  for  helping  himself  to  what  he  believes  to 
be  his.  Again,  there  are  certain  weak-minded  persons, 
especially  those  with  insane  inheritance,  who  may  be 
incapable  of  education  as  far  as  the  rights  of  property 
are  concerned.  In  many  states  of  weak-mindedness 
following  acute  attacks  of  insanity  there  is  a  tendency 
to  collect  rubbish  of  all  kinds,  and  to  pilfer  generally, 
and  the  pilfering  may  be  done  with  all  the  apparent 
design  and  consideration  of  a  skilled  thief.  It  has 
been  said,  too,  that  epileptics  are  dangerous  in  a  similar 
way.  Theft  is  common  in  general  paralytics,  in 
imbeciles,  and  in  patients  suffering  from  the  effect 
of  fccute  insanity.  There  are  other  crimes  against 
property  which  may  well  be  considered  under  the 
same  head,  certain  of  them  having  been  classified  by 
former  writers  as  independent  diseases.  Thus  we 
have  heard  oi  pyromania  in  the  same  classification  as 
kleptomania.  As  a  rule,  monomania  of  this  kind  are 
either  the  result  of  imperfect  intellectual  and  moral 
development  due  to  strong  nervous  inheritance,  or  else 
they  are  the  vestiges  of  a  nervous  storm  which  has 
now  passed.     I  have  met  with  one  or  two  cases  in  which 


Chap.  XXIII.]  Homicidal  Mania.  467 

lads  of  from  ten  to  fifteen  have  been  pyromaniacs, 
and  liave  been  the  cause  of  endless  trouble,  in  conse- 
quence of  their  tendency  to  burn  or  destroy  everything 
which  interfered  with  their  immediate  comfort. 

Suicidal  and  homicidal  maniacs  have  been  specially 
classed  in  consequence  of  their  grave  relationship  to 
the  community  at  large.  As  far  as  suicide  is  con- 
cerned, I  have  already  devoted  attention  to  this  point ; 
but  here  I  shall  refer  to  conditions  leading  to  homicidal 
impulses  as  seen  in  asylums,  and  from  these  will  be 
seen  some  of  the  chief  dangers  to  society  arising  from 
insanity. 

Homicide  may  be  the  result  of  simple  uncontrolled 
passion,  the  loss  of  control  following  physical  or 
mental  weakness ;  it  may  follow,  as  we  have  seen, 
a  delusion  as  to  persecution,  patients  being  more 
especially  dangerous  when  they  believe  that  their 
strength,  moral  character,  or  situation,  are  being 
affected  by  conspiracy  or  plot ;  or  when  they  hear 
voices  telling  them  that  an  organised  body  like  the 
Jesuits  or  Freemasons  is  going  to  injure  wife  or 
children.  Probably  the  most  dangerous  of  all  patients 
are  those  who  distinctly  believe  themselves  to  be 
persecuted,  or  hinted  at ;  such  patients,  as  the  one 
I  have  described  under  delusional  insanity  (page  241), 
are  marked  examples  of  the  danger  which  arises 
from  these  cases. 

Homicide  or  suicide  may  occur  as  a  natural  out- 
come of  nervous  sensitiveness.  One  patient  knocked 
another  down  because  he  coughed ;  and  he  attacked 
another  weak-minded  patient  because  he  pushed  his 
bedroom  door  twice;  he  said,  after  attacking  him 
violently,  that  if  he  did  it  again  he  should  murder 
him,  and  I  believe  he  would  have  done  his  best  to 
that  end,  if  not  prevented.  To  show  the  extreme 
danger  there  is  with  such  cases,  I  may  say  that,  after 
careful  consideration  and  a  prolonged  interview  with 


468     Insanity  and  Allied  Neuroses.  [Chap,  xxiii. 

this  patient,  he  told  me  that  although  he  abhorred 
violence,  he  felt  that  he  must  protect  himself  on  the 
one  hand  ;  and  that  as  soon  as  he  found  annoyances 
beyond  his  endurance  or  control,  he  should  destroy 
himself ;  and  that  he  would  leave  it  for  me  to  judge 
whether  he  could  be  deterred  from  his  end  if  once  he 
determined  on  it.  Violence  may  arise  from  a  natural 
outgrowth  of  insane  vanity  ;  some  patients  are  sources 
of  danger  from  the  way  they  assert  their  power  and 
importance.  One  patient  in  Bethlem  attempted  to 
murder  two  others,  because  one  placed  his  hands 
upon  him,  and  because  the  other  did  not  sufficiently 
comprehend  his  exalted  position  ;  the  history  of  the 
man  shows  that  for  years  he  has  been  slowly  passing 
into  a  condition  of  pride  and  unrestrained  passion 
only  compatible  with  insanity. 

Homicide  or  suicide  may  be  the  direct  result  of 
what  is  called  by  patients  "influence."  In  some  there 
is  a  feeling  of  weakness  and  inability  to  decide 
upon  what  is  best  to  be  done,  but,  on  the  other 
hand,  they  are  conscious  of  their  actions,  though 
they  cannot  prevent  themselves  from  following  cer- 
tain courses.  This  weakness,  associated  with  the  ten- 
dency to  action  which  they  cannot  control,  they  call 
"influence."  On  the  other  hand,  there  are  similar 
cases  under  "influence,"  which,  without  in  any  way 
describing  themselves  as  weak-minded  or  feeble  of  pur- 
pose, say  that  there  is  something  within  them  driving 
them  to  action  ;  some  such  cases  call  the  motive  power 
the  devil,  but  others  leave  the  influence  unnamed.  In 
some  patients,  neither  simple  loss  of  control,  delusions, 
hallucinations,  persecutions,  or  influences,  have  any 
effect  in  the  production  of  homicidal  tendencies,  but 
simple  weak-mindedness  seems  to  be  connected  with  a 
childish  tendency  to  destructiveness,  and  therefore  the 
crime  is  a  perfectly  wanton,  causeless  act.  After 
all,  the  difliculties  which  arise  in  cases  of  homicide  are 


Chap.  XXIII.]  Homicidal  Mania.  469 

not  such  as  can  be  so  readily  cleared  up  even  when 
the  patient  has  been  under  observation  in  an  asylum. 
I  would  say  that,  in  considering  a  murder,  the  first 
question  to  be  asked  is,  What  was  the  assigned  cause 
for  the  crime  %  was  it  the  natural  development  of 
the  man's  surroundings  and  habits  %  To  my  mind 
certain  crimes  themselves  are  sufficient  evidence  of 
mental  unsoundness.  If  a  person  with  or  without 
some  sudden  shock  become  completely  changed  in  his 
domestic  relations,  if  the  man  who  was  a  good  hus- 
band and  kind  father  kills  wife  or  child,  without  there 
being  any  established  delusion,  I  think  the  crime 
itself  is  sufficient  to  cause  a  iwiiina  facie  belief  in  the 
existence  of  mental  unsoundness.  The  chief  points, 
then,  are  the  apparent  causelessness  of  the  crime, 
the  utter  want  of  relationship  between'  the  crime 
and  the  supposed  end  to  be  attained,  the  relation- 
ship between  the  crime  and  any  delusions,  the  es- 
tablishment of  any  insane  or  nervous  inheritance, 
or  the  proof  that  the  patient  himself  at  one  time 
or  another  has  been  of  unsound  mind  or  epileptic. 
Next  after  the  consideration  of  the  causation  of  the 
crime  itself  and  its  surroundings,  it  is  important  to 
obtain  evidence  as  to  acts  immediately  preceding  and 
immediately  following  the  deed,  as  well  as  to  find 
out  the  details.  Insane  patients  possessed  by  delu- 
sions, or  driven  by  influence,  may  nevertheless  nerve 
themselves  to  act  by  taking  stimulants,  and  yet  this 
must  not  be  attributed  to  sanity,  nor  must  the  crime 
itself  be  laid  to  the  charge  of  drink. 

A  crime  may  be  committed,  and  when  the  perpe- 
trator is  discovered,  or  when  he  gives  himself  up,  he 
may  appear  to  be  quite  reasonable.  This  is  especially 
the  case  in  epileptic  and  impulsive  cases.  After  the 
outbreak  of  passion  there  may  be  are-establishment  of 
the  intellectual  balance,  and  it  may  appear  as  if  with 
the  act  of  violence  temporary  sanity  at  all  events  has 


470     Insanity  and  Allied  N'euroses.  [Chap.  xxiii. 

returned.  It  is  difficult  to  get  the  lay  mind  to  under- 
stand that  acts  of  this  kind  can  really  be  due  to  tem- 
porary insanity.  But  the  same  holds  good  both  with 
suicidal  attempts  and  with  homicidal  attacks.  There 
may  be  almost  immediate  improvement  following  the 
outbreak. 

One  special  subdivision  of  this  subject  may  be 
referred  to  here,  namely,  infanticide.  To  begin  with, 
concealment  of  birth,  which  is  the  first  degree  of  this 
crime,  may  follow  in  a  person  of  unsound  mind  who 
is  delivered  of  a  child.  In  one  case  I  myself  saw  a 
woman  with  a  fully  developed  child  in  the  bed,  the 
mother  having  been  delivered  without  any  evidences 
of  pain,  so  that,  although  there  were  neighbours  in 
the  same  house,  the  delivery  took  place  without  their 
knowing  it ;  yet  the  mother  herself  said,  and  I  believe 
truthfully,  when  I  first  saw  her,  that  she  did  not 
know  anything  had  happened.  A  woman,  then,  may 
be  delivered  without  knowing  that  a  child  has  been 
born;  but  in  such  a  case  the  child  and  the  placenta 
will  probably  be  where  they  were  delivered,  in  an 
unaltered  condition,  no  means  having  been  taken  to 
separate  the  cord.  Next,  as  we  have  seen  when 
considering  puerperal  insanity,  there  may  be  a  frenzy 
associated  with  the  birth  of  a  child,  which  may 
disturb  the  mental  balance  for  a  longer  or  a  shorter 
period.  Next  there  may  be  an  ephemeral  mania 
associated  with  the  oncoming  of  the  milk.  In  all 
these  cases  the  murderous  act  may  be  done  without 
premeditation,  and  with  little  or  no  recollection  of 
what  has  happened.  With  puerperal  insanity  there  is 
commonly  a  dislike  to  both  husband  and  child ;  there 
being  in  one  case  a  nervous  irritability  which  prompts 
the  mother  to  get  rid  of  the  crying  child  which  dis- 
turbs her  rest ;  or,  on  the  other  hand,  she  may  not 
believe  that  the  child  is  hers  at  all,  or  she  may 
think  its  birth  has  alienated  her  husband's  afifection. 


Chap.  XXIII.]  Self-accusation.  471 

With  puerperal  melancholia  the  mother  may  have 
some  delusion,  fancying  that  the  child  will  be 
starved,  or  that  it  is  already  suffering  from  serious 
ailment ;  or  she  may  kill  it  simply  to  send  it  direct  out 
of  this  world  into  a  happier  state.  With  the  weak- 
ness following  lactation,  or  in  cases  in  which  rapid 
child-bearing  has  produced  exhaustion,  great  weakness 
and  melancholia  may  occur,  in  which  the  mother 
butchers  her  whole  family,  generally  possessed  by  the 
idea  that  she  is  benefiting  them  and  saving  them 
from  further  misery.  The  law  rightly  in  this  particular 
looks  upon  the  crime  itself  as  sufficient  evidence  of 
the  insanity  ;  that  a  loving  mother  should  destroy  her 
offspring  is  unnatural  and  unreasonable,  and  ought 
not  to  be  considered  as  an  act  for  which  she  can  be 
held  responsible;  and  it  would  be  well  if  the  law 
would  look  more  frequently  at  crimes  as  symptoms 
of  insanity  in  other  cases,  rather  than  compel  experts 
to  discover  other  collateral  evidences  of  insanity,  and 
then  decline  to  accept  them  because  they  have  no 
definite  connection  with  the  act  itself.  Infanticide, 
although  generally  a  crime  committed  by  the  mother, 
may  be  perpetrated  by  the  father  also  \  and  the  case 
of  Goulclstone,  occurring  in  the  year  1883,  was  an 
example  of  a  man  who,  being  temperate,  well-behaved, 
and  industrious,  but  belonging  to  a  slightly  nervous 
stock,  killed  all  his  children  in  a  fit  of  despondency, 
which  was  out  of  relationship  to  all  surrounding 
circumstances,  the  crime  depending  on  his  neurotic 
constitution.  In  his  case^  in  the  end  it  was  decided 
that  he  was  of  unsound  mind,  and  that  he  should  be 
reprieved  and  sent  to  Broadmoor. 

One  other  point  deserves  notice  and  consideration 
here,  and  that  is  the  question  of  self-accusation.  When 
any  serious  crime  is  committed  some  person  is  sure  to 
give  himself  up  to  justice,  saying  that  he  is  the  per- 
petrator  of    the    crime.      In    many    such    cases    the 


472     Insanity  AND  Allied  Neuroses.  [Chap,  xxiii. 

behaviour  of  the  person  is  quiet  and  self-possessed, 
and  the  police  are  sufficiently  convinced  to  take  him 
in  charge,  and  thus  delay  is  caused,  which  may  en- 
able the  real  criminal  to  effect  his  escape.  One  of 
the  most  common  conditions  under  which  these  self- 
accusations  occur  is  drunkenness,  and  this,  as  a 
rule,  is  cleared  up  within  twenty-four  hours  by  the 
recantation  of  the  person,  or  by  the  development 
of  other  alcoholic  symptoms.  In  the  other  cases 
it  will  generally  be  found  that  the  person  has  been 
suffering  from  mental  depression  and  sleeplessness, 
with  extraordinary  restlessness  and  tendency  to 
wander  for  some  little  time  before  the  self-accusa- 
tion ;  in  fact,  that  he  has  been  like  so  many  other 
persons  suffering  from  early  insanity,  looking  for  some 
interpretation  of  his  misery,  and  on  hearing  of  this 
crime  he  feels  that  he  must  in  some  way  or  other  have 
been  the  cause  of  it.  We  see  this  condition  in 
patients  in  asylums ;  thus,  on  the  death  of  George 
Sand  one  patient  was  deeply  concerned,  as  he  main- 
tained that  it  was  by  his  action  that  she  died  ;  and 
when  the  Emperor  of  E-ussia  was  assassinated,  seve- 
ral people  were  willing  to  accept  the  responsibility 
of  the  crime.  It  is  possible  even  to  meet  with  two 
persons  supporting  each  other  in  one  delusion;  and 
in  one  police  district  in  London  I  was  told  by  the 
divisional  surgeon  that  a  whole  family  supported  the 
insane  statement  of  the  father,  being  themselves  weak- 
minded  and  influenced  by  his  delusion.  Hence 
extraordinary  complications  maj?-  arise  from  the  occur- 
rence not  only  of  self-accusation,  but  of  combination 
or  agreement  of  persons  of  unsound  mind  upon  the 
same  delusion. 

Besides  the  crimes  to  which  I  have  referred,  rape, 
unnatural  offences,  and  the  like,  may  occur  in  con- 
nection with  insanity.  The  imbecile  or  idiot  may 
have   some   sexual    desire,    which    he    may    forcibly 


Chap.  XXIII.]    Testamentary  Capacity.  473 

gratify.  The  offspring  of  nervous  patients,  of  the  moral 
imbecile,  or  the  senile  dement,  may  be  guilty  of 
exposing  their  persons  in  public,  or  criminally  assault- 
ing young  children  or  old  women  without  being  re- 
sponsible for  the  act.  Similar  crimes  are  committed 
by  the  general  paralytic  in  the  earlier  stage  of  excite- 
ment and  in  weak-mindedness,  and  by  epileptics.  Loss 
of  control  may  be  very  well  marked,  and  may  result 
in  some  brutal  assault.  Similar  acts  may  occur  in 
old  persons,  in  whom  lust  reappears  as  an  evidence  of 
senile  weakening.  Attacks  of  the  kind  described  may 
result  from  delusions.  To  sum  up :  unnatural  or 
brutal  offences  of  a  sexual  nature  may  result  from 
undeveloped  higher  control ;  from  loss  of  the  same 
control ;  or  from  degeneration  or  disease,  in  which 
case  they  may  follow  simply  from  delusions.  I  have 
met  with  one  case  of  a  young  single  man  given  to 
masturbation  who  had  complete  sensual  perversion, 
so  that  he  lusted  after  men,  not  women. 

Testamentary  capacity. — It  will  be  impos- 
sible for  me  under  this  heading  to  consider  all  the 
bearings  of  insanity  upon  the  validity  of  wills,  but 
there  are  certain  points  which  I  may  be  able  to  make 
clear  in  reference  to  mental  conditions  which  distinctly 
prevent  persons  from  performing  legal  acts.  The  law 
of  England,  in  considering  a  will,  is  much  more 
influenced  by  the  will  itself  than  by  any  statement 
or  evidence  as  to  the  mental  condition  of  the  person 
making  a  will.  If  a  will  is  distinctly  the  representa- 
tion of  the  desires  expressed  by  the  individual  during 
his  life,  it  would  be  upheld,  although  the  person 
could  be  proved  to  have  been  insane.  Again,  a  will 
made  by  a  lunatic  during  a  period  of  sanity,  if  con- 
sistent, would  probably  be  upheld ;  and  it  has  been 
suggested  that  persons  of  unsound  mind,  even  though 
suffering  from  general  paralysis,  should  be  allowed  to 
make   a  will   during  periods   of  sanity,   even    though 


474     Insanity  AND  Allied  Neuroses.  [Chap,  xxiir. 

still  under  certificates.  The  will,  then,  will  be  con- 
sidered good  or  bad  rather  from  its  nature  than  from 
the  conditions  under  which  it  was  signed. 

But  certain  wills  are  opposed,  and  the  chief  grounds 
for  opposition  are  incapacity  or  undue  influence.  The 
incapacity  may  depend  upon  simple  weak-mindedness, 
or  upon  any  conditions  in  which  there  is  such  unsound- 
ness of  mind  as  is  likely  to  affect  the  will  itself.  No  per- 
son with  delirious  ideas,  such  as  one  sufferingfrom  mania 
or  from  active  melancholia.,  could  make  a  will  which 
might  not  be  upset.  But  the  more  common  condition 
of  inability  to  will  results  from  weak-mindedness.  This 
is  most  commonly  met  with  in  cases  where  the  patients 
are  suffering  from  mental  changes  due  to  senility. 
Weak-mindedness  may  be  congenital,  or  may  be  the 
result  of  an  acute  attack  of  insanity,  or  age  ;  so  that 
simple  weak-mindedness,  in  which  a  person  may  be 
readily  influenced  to  do  wicked  or  unjust  foolish 
things,  may  occur  from  congenital  weakness,  or  may 
follow  acute  mental  disorder,  or  may  result  from  age 
alone,  or  from  mental  depression  occurring  with  age, 
or  from  apoplexy  or  similar  brain  disease. 

Imbeciles  need  scarcely  be  considered  farther,  but 
patients  suffering  from  weak-mindedness  due  to  other 
attacks  of  insanity  merit  a  little  further  consideration. 
After  an  acute  attack  of  insanity  some  patients  are  never 
themselves  again  ;  some  never  forgive  their  relatives 
for  having  sent  them  to  an  asylum ;  and  I  maintain 
emphatically  that,  in  my  experience,  patients  who  are 
discontented  after  severe  attacks  of  insanity  are  still 
to  be  considered  of  unsound  mind,  and  likely  to  make 
wrong  dispositions  of  their  property  in  consequence 
of  false  ideas  about  their  relations.  Again,  after 
some  attacks  of  insanity,  mental  weak-mindedness 
may  result,  as  shown  by  emotional  instability  ;  such 
patients  often  take  to  emotional  forms  of  worship,  and 
are  easily    moved   to   leave  their   property  to    some 


Chap.  XXIII.]    Testamentary  Capacity.  475 

cliurch  or  institution  for  whicli  in  their  lives,  while 
sane,  they  had  little  sympathy. 

The  weak-mindedness  of  age  may  be  marked  by 
similar  emotional  or  intellectual  feebleness ;  it  is  not 
uncommonly  marked  by  querulous  and  exacting  con- 
duct on  the  part  of  the  patients  towards  those 
who  have  devoted  years  to  their  service,  a  for- 
getful ness  of  all  past  sacrifices,  and  an  apparent 
loss  of  memory  of  old  relationships  and  present 
duties.  In  senile  weak-mindedness  persons  are  easily 
influenced,  and  in  such  states  wills  or  codicils  may 
have  been  executed.  If  the  memory  can  be  proved 
to  be  very  defective,  so  that  it  can  be  established 
that  the  executor  did  not  remember  the  existence 
of  his  heirs- at- law,  it  is  probable  that  a  will  leaving 
property  away  from  them  would  be  successfully  con- 
tested. In  senile  weak-mindedness,  too,  it  is  not 
uncommon  to  meet  with  persons  influenced  by  lower 
animal  motives.  Some  old  men  sufier  from  sexual 
passion  as  a  form  of  weakness,  and  they  may  be  induced 
by  it  to  do  many  weak  or  wicked  things. 

Probably  weak-mindedness,  associated  with  apo- 
plexy, is  the  most  common  cause  of  contests  about 
wills.  I  would  begin  by  saying  that  although  apo- 
plexy is  frequently  associated  with  weak-mindedness, 
yet  it  is  very  common  to  meet  with  persons  Avho 
have  suffered  from  apoplexy,  and  yet  who  are  perfectly 
able  to  make  a  will.  I  have  had  on  one  or  two  occa- 
sions to  examine  persons  who,  having  suffered  from 
apoplexy,  were  going  to  make  their  will,  and  being 
anxious  that  they  should  not  give  rise  to  litigation, 
took  the  trouble  to  have  expert  opinions  as  to  their 
mental  condition  before  signing  their  wills.  After 
apoplexy  aphasia  is  common,  and  I  have  seen  several 
wills  contested  because  the  testator  could  not  be  under- 
stood by  speech.  Perfect  testamentary  capacity  may 
exist  with  aphasia;  but  in  some  cases  in  which  aphasia 


476     Insanity  AND  Allied  Neuroses.  [Chap,  xxiii. 

and  amnsesia  co-exist,  the  patient  may  be  unable  to 
understand  the  life  relationships  sufficiently  to  make 
a  just  will ;  or,  he  may  not  himself  make  the  will,  but 
may  be  too  readily  influenced  by  anyone  suggesting  to 
him  what  the  contents  of  the  will  should  be.  If,  after 
apoplexy,  memory  is  retained,  if  there  is  no  special 
change  in  the  emotional  nature,  and  if  there  are  no 
signs  of  change  of  character  and  disposition  which 
would  directly  influence  the  opinion  which  the  testator 
holds  of  his  near  relations,  it  is  clear  that  the  patient 
should  be  allowed  to  make  a  will. 

Besides  the  above  conditions,  we  must  remember 
that  epilepsy,  by  producing  mental  weakness,  may 
incapacitate  a  person  from  making  a  will.  Before  an 
outbreak  of  insanity,  although  the  patient  may  appear 
reasonable  at  the  time,  there  may  be  a  moral  perver- 
sion causing  him  to  dislike  and  suspect  his  relations, 
which  may  induce  him  to  revoke  his  old  will  and  make 
a  new  one;  this  is  more  common  with  those  who 
have  suffered  from  previous  attacks  of  insanity,  fol- 
lowed by  former  seclusions. 

The  most  dangerous  symptom,  as  far  as  will- 
making  is  concerned,  is  the  general  suspicion  that 
people  are  in  league  against  the  testator.  This  symp- 
tom of  suspicion  may  either  cause  the  person  to  destroy 
all  wills,  or  to  make  a  will  in  favour  of  some  stranger 
or  of  some  charitable  institution.  The  onset  of  melan- 
cholia may  also  be  associated  with  the  revocation  or 
alteration  of  the  will,  so  that  a  pei^son  who  thinks  that 
he  has  not  made  a  good  use  of  his  life  and  property 
may  leave  his  whole  fortune  away  from  his  relations 
to  some  religious  body.  To  conclude,  nearly  every- 
thing depends  upon  the  nature  of  the  will  itself; 
but  wills  may  be  shown  to  be  unreasonable  from 
the  mental  weakness  of  the  testator,  or  because  he 
was  unduly  influenced,  and  I  have  pointed  out 
some    of    the    various    conditions    in    which    mental 


Chap.  XXIII.]    The  Medical   Certificate.  477 

weakness  may  occur,  or  in  whicli  influence  may  be 
exerted. 

Practical  and  social  questions  connected 
with  insanity. — Under  this  head  I  shall  consider, 
first,  in  what  circumstances  it  is  necessary  that 
patients  should  be  placed  under  certificates,  then  the 
circumstances  which  influence  the  selection  of  a  place 
of  treatment  for  the  insane,  whether  the  patient  should 
be  sent  to  an  asylum,  should  be  treated  at  home,  or 
in  the  family  of  a  stranger  in  what  is  called  "  single 
care."  There  are  many  other  important  questions, 
such  as  the  use  of  travelling  and  the  continuing  to 
follow  the  same  trade  or  profession,  and  the  more 
important  social  question  of  marriage. 

When  called  to  see  a  patient  of  unsound  mind,  one 
of  the  first  and  important  questions  to  decide  is, 
whether  a  patient  can  be  safely  and  satisfactorily 
treated  without  being  under  certificates.  Generally 
relations  will  sacrifice  a  good  deal  rather  than  have 
their  friends  "  made  lunatics,"  as  they  express  it. 
There  is  but  one  point  to  decide,  and  that  is,  whether 
it  is  necessary,  in  any  way,  forcibly  to  control  the 
actions  of  the  patient.  If  this  is  done  he  should  be 
under  certificates.  If  treated  in  his  house,  and  if  he 
is  childish  and  not  obstinate  or  wilful,  he  may  be 
easily  treated  without  certificates,  but  if  of  unsound 
mind  and  treated  either  in  a  stranger's  house  (whether 
with  a  relation,  servant,  friend,  or  doctor),  he  should 
in  every  case  be  under  the  legal  restrictions  of  cer- 
tificates. It  will  sometimes  happen  that  doctors  will 
decline  to  sign  certificates  of  insanity,  especially 
in  the  case  of  first  attacks  in  young  patients,  such 
as  attacks  of  hysterical  and  puerperal  insanity. 
In  such  cases,  the  person  who  receives  the  patient 
into  his  house  should  obtain  a  certificate  from  the 
doctor  or  doctors  who  consider  that  the  patient  is  not 
insane,    to    the    eff'ect    that    he    is    not    insane,    but 


478     Insanity  AND  Allied  i\^Z7i?c5^5".  [Chap,  xxiii. 

requires  control.  The  next  point  is  as  to  where 
the  patient  should  be  treated.  First  of  all  I  would 
say  that  the  question  of  the  liberty  of  the  subject  is, 
after  all,  one  of  means.  A  man  with  unlimited  wealth 
need  scarcely  ever  be  sent  to  an  asylum  ;  but  I  think 
that,  although  he  may  be  treated  at  home,  it  does  not 
follow  that  that  form  of  treatment  is  the  best;  and 
though  wealth  may  secure  many  things,  it  can  neither 
buy  health,  nor  necessarily  alone  obtain  the  best  sur- 
roundings for  a  person  of  unsound  mind.  Persons 
of  moderate  means  are  those  for  whom  one  has 
generally  to  advise,  and  the  advice  may  be  arranged 
under  the  following  heads  :  Travelling  with  a  com- 
panion or  doctor ;  treatment  in  a  private  home ; 
treatment  in  an  asylum  or  hospital  of  some  kind. 

Travelling  is  undoubtedly  of  great  service  in  some 
cases;  but  I  for  one  must  protest  emphatically  against 
the  fashion  of  sending  patients,  suffering  from  all 
kinds  of  nervous  disorder,  away  from  their  homes  on 
the  chance  of  some  of  them  deriving  benefit.  Travel- 
ling is  useful  in  many  young  cases  suffering  from 
weakness,  bodily  or  mental,  especially  in  those 
suffering  from  morbid  self -consciousness,  and  for  those 
with  hypochondriacal  tendencies.  The  self-conscious 
girl,  who,  having  spent  five  or  six  of  her  developing 
years  in  hard  monotonous  book-learning,  is  benefited 
by  a  course  of  fresh  sense  impressions,  which  travel 
and  change  supply.  Going  from  England  to  the 
Continent,  visiting  Paris  and  the  German  cities,  where 
art  and  music  can  be  studied  in  comfort  and  without 
dissipation,  to  be  succeeded  by  a  sojourn  in  Switzer- 
land or  in  the  Mediterranean,  will  frequently  establish 
for  life  a  young  nervous  system  which  was  tottering 
from  over-strain.  The  over-worked  student  who,  after 
an  easy  life  at  school  and  college,  has  freshly  awakened 
to  the  importance  of  real  continuous  hard  work  if  he 
wishes  for  success  in  his  profession ;  who,  without  the 


Chap. XXIII.]     Travelling  as  a  Remedy.  479 

discipline  foi'  work,  and  regardless  of  the  warnings 
given  by  indigestion  and  sleeplessness,  often  continues  to 
work,  stimulated  by  coffee  and  cold  water,  and  neglect- 
ing his  old  physical  exercises,  breaks  down  under  some 
trifling  moral  or  physical  shock.  Such  an  one,  unless 
removed  from  his  old  surroundings  and  occupations, 
will  run  a  great  risk  of  becoming  insane.  Change 
and  vigorous  exercise,  gradually  increased  in  quantity 
and  continued  for  several  months^  will  often  have  the 
most  beneficial  results.  In  adolescent  insanity,  with 
or  wdthout  sexual  vice,  companionship,  and  the  active 
exercise  of  travelling  are  very  beneficial.  Many  a 
young  fellow  who  is  developing  unhealthy  religious 
ideas,  loses  his  fear  of  the  unpardonable  sin  after  six 
months'  knapsack  work  in  England  or  on  the  Con- 
tinent. I  oppose  the  sending  abroad  of  any  cases  in 
which  there  is  a  ground  for  suspecting  general  paralysis, 
or  in  which  apoplexy  was  a  cause  of  break  down.  A 
sea  voyage  is  useful  when  the  physical  health  of  the 
patient  precludes  active  exercise,  and  when  there  is  no 
distinctly  suicidal  tendency,  or  any  tendency  to  sudden 
impulses  to  violence.  Sea  voyages  are,  therefore, 
useful  in  the  milder  forms  of  hypochondriasis,  and  in 
cases  in  which  some  lung  trouble  is  threatening,  and 
in  others  in  which  there  has  been  dyspepsia,  sleepless- 
ness, and  general  loss  of  tone.  The  time  of  year  will 
determine  the  kind  of  travelling  which  must  be 
advised,  the  sunshine  of  the  south  of  Europe  being 
useful  during  the  wdnter  and  early  spring,  and  the 
bracing  mountain  scenery  being  most  useful  in  summer 
and  autumn.  For  a  long  voyage,  that  to  Australia 
probably  provides  the  best  change  for  such  patients, 
but  the  Cape  is  more  handy,  and  often  affords  suffi- 
cient change.  Travelling,  then,  is  useful  in  milder 
cases  of  insanity  ;  in  cases  threatening  with  nervous 
break-down,  and  it  may  be  of  the  utmost  value  after 
recovery  from  an  attack  of  insanity,  or  in  cases  where 


480     Insanity  and  Allied  Neuroses.  [Chap.  xxiii. 

the  attacks  are  in  the  habit  of  coming  on  periodically 
at  a  certain  time  each  year,  or  each  second  or  third 
year. 

Next  as  to  home  treatment.  The  first  considera- 
tion is,  that  the  person  of  unsound  mind  has  probably 
others  about  him  who  are  nervously  unstable,  there- 
fore he  will  not  be  treated  in  the  most  considerate 
way  by  them,  and  again  his  influence  may  be  disas- 
trous to  those  about  him.  It  is  often  my  experience 
to  find  it  perfectly  impossible  to  treat  an  insane 
person  in  his  own  home,  because  of  the  thwarting 
action  of  his  relations.  And,  on  the  other  hand,  I 
have  seen  cases  in  which  an  insane  brother  has  started 
insanity,  hitherto  unknown  in  the  family,  which 
passed  from  member  to  member  till  three  or  four  had 
become  insane. 

Home  cure  is  only  suitable  for  cases  in  which  there 
is  hope  of  speedy  recovery,  and  where  there  are  judi- 
cious friends  and  sufficient  space.  Insanity  following 
fevers,  insanity  due  to  childbirth,  may  often  be  success- 
fully treated  at  home.  Care  should  be  taken  that 
the  patient  is,  if  possible,  on  the  ground  floor,  so  as  to 
avoid  accidents  from  precipitation  ;  and,  although  the 
patient  is  at  home,  he  must  not  be  too  much  visited  by 
near  relations.  In  fact,  the  success  of  home  treatment 
depends  upon  the  quiet  of  home,  with  the  absence  of 
relations. 

Next,  as  to  the  cases  suited  to  single  care.  Under 
"  legal  considerations "  I  shall  point  out  the  neces- 
sity of  having  certificates  even  for  a  single  case 
where  insanity  is  pronounced,  and  where  there  is 
any  real  restriction  to  liberty.  It  is  often  of  the 
utmost  importance  to  have  young  developing  children 
belonging  to  highly  nervous  families  removed  from  their 
homes,  but  yet  placed  under  home-like  treatment  and 
discipline.  Neurotic  boys  are  specially  likely  to  suflfer 
from  the  surroundings  of  a  mixed  school ;  and  I  advise 


Chap.  XXIII.]  Single  Care.  481 

that  such  patients  be  kept  in  the  house  of  a  medical 
man  who  has  had  some  experience  of  nervous  disorders, 
at  the  same  time  that  he  attends  school,  or,  at  all  events, 
is  taught  with  other  children.  Epileptic  children,  too, 
are  better  educated  in  private  houses.  They  often  re- 
quire special  education,  and  also  their  epileptic  fits 
are  distressing,  and  may  be  injurious  to  other  children. 
In  the  same  way  the  unstable  girl  at  puberty,  and  the 
hypochondriacal  young  man,  may  require  skilled  super- 
vision for  a  year  or  two  from  seventeen  or  eighteen 
years  of  age,  and  this  is  best  effected  by  private  care. 
With  large  means  any  case  can  be  treated  at  home,  the 
necessity  being  sufficient  skilled  attendance  both  by 
night  and  by  day  j  cases  of  insanity  due  to  drink  or 
to  acute  physical  disorder  may  be  also  satisfactorily 
treated. 

My  own  opinion  is  that  it  is  neither  for  the  wel- 
fare nor  for  the  comfort  of  chronic  lunatics  to  be 
treated  alone  ;  and  I  believe  that  the  present  reaction 
in  favour  of  sending  patients  to  private  houses  rather 
than  to  private  asylums  will  be  the  cause  of  scandals 
such  as  arose  in  former  times  from  the  keeping  of 
lunatics  in  private  houses.  First,  the  chronic  lunatic, 
if  placed  in  a  house  by  himself  with  two,  three,  or  four 
private  keepers,  is  in  the  position  of  a  man  controlled 
by  his  servants,  and  having  no  companionship  or  occu- 
pation ;  for  it  is  absurd  to  suppose  that  a  cultured  man 
is  happy  when  he  is  watched  momentarily  by  inferiors, 
is  forced  to  take  his  meals  by  or  with  them,  and  for 
amusement  expected  to  play  games  with  his  servants. 
Although  it  is  somewhat  an  improvement  when  a  young 
medical  man  is  put  in  charge,  yet  the  want  of  experi- 
ence, and  the  natural  desire  for  some  freedom  on  the 
part  of  the  doctor,  does  not  insure  the  perfect  comfort 
of  the  lunatic. 

Many  forms  and  degrees  of  weak-mindedness  natu- 
rally may  be  treated  at  home  or  in  the  home  of  a  doctor ; 
F  F — 14 


482     Insanity  and  Allied  Neuroses.  [Chap,  xxiii. 

patients  suffering  from  the  more  advanced  state  of 
general  paralysis  may  also  be  managed  in  single  care ; 
but  in  the  case  of  a  patient  suffering  from  hallucina- 
tions and  delusions  it  seems  to  me  that  he  is  happier 
and  better  off  in  a  small  private  asylum  or  hospital 
than  under  private  care.  Whatever  the  statistics 
of  cures  may  appear  to  show,  1  am  quite  sure  that, 
other  things  being  equal,  more  patients  get  well 
when  associated  than  when  in  single  charge ;  and 
although  it  may  be  said  that  private  asylums  are 
hot-beds  of  farming  in  lunacy,  yet  self-interest  is,  at 
least,  as  great  in  single  care  as  when  a  dozen  paying 
patients  contribute  to  the  income  of  the  proprietor. 
Patients  who,  from  their  smallness  of  means,  or  from 
the  nature  of  their  symptoms,  cannot  be  treated  at 
home,  may  either  be  sent  to  one  of  the  hospitals  for  the 
insane,  or  else  to  private  asylums  {see  Appendix) ;  or, 
if  means  be  entirely  wanting,  they  may  be  sent  to  their 
county  asylum. 

About  the  most  important  social  question  that 
the  practitioner  will  be  asked  is,  whether  a  patient, 
if  he  recover,  should  be  allowed  to  return  to  his  former 
occupation.  The  advice  given  must  depend  upon  the 
nature  of  the  employment,  the  temperament  of  the 
man,  and  the  nsiture  of  his  insanity.  If  the  man  is 
an  emotional  unstable  person,  and  his  business  tends 
to  throw  him  in  the  way  of  drink,  gambling,  or  heavy 
speculation,  he  should  be  induced  to  follow  rather  the 
mechanical  or  clerical  part  of  his  business,  and  leave 
the  active  side  to  others.  The  morbidly  self-conscious 
man  had  better  give  up  sedentary  occupations,  and  try 
his  hand  at  farming  or  mechanical  pursuits.  It  may 
happen  that  a  change  of  occupation  for  a  year  or  two 
at  about  eighteen  years  of  age  may  enable  the  nervous 
student  to  return  to  the  work  necessary  for  him  to 
enable  him  to  follow  the  profession  of  his  choice.  The 
most  important  indications  should  be  drawn  from  the 


Chap.  XXIV.]  Legal  Rela  tionships  of  Insanity.  483 

effect  of  the  return  to  old  surroundings,  and  if  it  is 
found  that  with  each  return  to  study  or  the  office 
mental  disorder  reappears,  it  is  evident  that  some 
change  in  life  must  be  made.  Business  relationships  are 
difficult  to  decide  upon ;  but  there  are  social  ones  of 
even  greater  difficulty,  and  when  a  question  of  marriage 
arises  it  is  hard  to  satisfy  either  one's  conscience  or 
one's  clients.  On  the  one  hand,  I  have  known  men 
and  women,  who  had  suffered  from  attacks  of  insanity, 
marry,  and  live  for  years  without  any  return  of  the 
disorder ;  but  the  risk  is  great.  On  the  other  hand, 
I  have  known  two  insane  people  marry,  and  have  seen 
their  insane  children,  and  I  have  seen  an  insane  man 
marry  while  still  nominally  under  control,  and  the  re- 
sults in  this  case  also  have  been  disastrous. 


CHAPTER   XXIY. 

LEGAL  RELATIONSHIPS  OF  INSANITY. 

Commissioners  in  lunacy — Private  lunatics — Chancery  lunatics  — 
Unlicensed  and  licensed  asylums  —  Registered  hospitals  — 
Medical  certificates — Delirium  tremens — Visitation  system — 
Pauper  lunatics — County  and  borough  asylums — Ill-treatment, 
escape,  recovery,  temporary  absence,  transfer,  and  death  of 
lunatics — ^Wandering  and  criminal  lunatics. 

In  this  section,  abandoning  the  pathological  distinc- 
tions of  disease,  I  shall  have  to  consider  briefly  the 
various  kinds  of  lunatics  that  may  arise,  in  connection 
with  their  social,  circumstantial,  and  legal  relation- 
ships existing  before  or  at  the  time  of  their  insanity ; 
the  nature  of  the  various  public  or  private  institutions 
provided  for  their  benefit,  and  the  manner  in  which 
such  are  regulated  and  controlled  by  the  state  ;  the 
manner,  also,  in  which  such  regulations  affect  and 
determine  the  welfare  of  the  patient,  the  obliga- 
tions of  the  physician,  and  the  procedure  of  those  in 


484     Insanity  and  Allied  Neuroses.    [Chap.  xxiv. 

charge  of  the  lunatic.  Though  it  will  be  my  object  to 
confine  myself  to  the  medico-legal  aspect  of  the  ques- 
tion, I  shall  not  be  precluded  from  briefly  referring  to 
the  mode  of  procedure  to  be  adopted  by  officials  of 
different  grades,  and  the  public  at  large,  in  reference 
to  circumstances  in  which  they  may  be  placed  with 
regard  to  lunatics. 

In  order  to  avoid  subsequent  confusion,  it  will  be 
desirable  that  I  should  in  the  first  place  briefly  ex- 
plain the  nature  of  the  official  hierarchy  instituted  by 
the  government  for  the  regulation  of  general  matters 
of  lunacy,  as  it  exists  at  present.  At  the  head  of 
this  branch  of  the  executive  is  the  Lord  Chancellor, 
subject  to  whose  control  all  those  having  jurisdiction 
in  lunacy  perform  their  functions.  Appeal  from  any 
decision  or  order  in  lunacy  made  by  him  is  transferred 
to  the  Court  of  Appeal  established  by  the  Supreme 
Court  of  Judicature  Act  of  1873.  Under  his  control 
there  are  two  Masters  in  Lunacy  and  one  Regis- 
trar in  Lunacy,  also  visitors  of  lunatics  appointed  to 
pay  visits  at  stated  intervals  to  such  patients  as  are 
immediately  under  the  jurisdiction  of  the  Lord  Chan- 
cellor. The  Masters  in  Lunacy,  the  visitors,  and  all  sub- 
ordinates, are  either  appointed  by  the  Lord  Chancellor 
himself,  or  are  subject  to  his  approval ;  the  masters 
being  Serjeants  or  barristers  of  ten  years'  standing  \ 
the  visitors,  of  whom  there  are  three,  being  two 
of  them  physicians,  who  at  the  time  of  election  must 
be  in  actual  practice,  and  the  third,  a  barrister  of  not 
less  than  five  years'  standing.  The  masters  are  bound 
upon  oath  faithfully  to  discharge  the  duties  of  their 
office.  The  visitors  are  required  to  give  up  the  prac- 
tice of  their  professions,  and  are  prohibited  from 
having  an  interest  in  any  house  licensed  for  the  re- 
ception of  lunatics. 

The  chief  functions  fulfilled  by  the  preceding 
officers  are  practically,  I  may  say,  the  determination, 


Chap.  XXIV.]    Commissioners  in  Lunacy.  485 

by  what  is  called  a  commission  in  lunacy,  as  tc 
whether  certain  private  individuals  are  sane  and 
capable  of  managing  their  own  affairs,  or  other- 
wise. The  mode  of  procedure  adopted  in  such  cases 
I  shall  have  occasion  briefly  to  describe  when  speak- 
ing of  private  lunatics.  Such  persons  as  are  found 
to  be  insane  by  inquisition  become  then  Chancery 
lunatics,  and  their  affairs  subject  immediately  to  the 
jurisdiction  of  the  Lord  Chancellor  and  the  Masters  in 
Lunacy,  who  make  the  requisite  orders  to  provide  for 
their  restraint,  and  the  just  administration  of  their 
property  during  the  time  of  their  illness  ;  the  visitors 
being  appointed  to  investigate  and  report  as  to 
whether  such  orders  are  duly  observed. 

In  former  days  an  administration  similar  to  and 
partially  identical  with  the  above  was  the  sole  existent 
branch  of  the  executive  to  which  was  entrusted  any 
control  over  general  matters  of  lunacy :  the  deter- 
mination of  the  insanity  of  private  patients,  and  the 
administration  of  their  affairs,  being  the  chief,  in  fact, 
almost  the  only  matter  taken  cognisance  of.  Now, 
however,  as  a  result  of  the  growing  influences  of 
public  opinion  and  the  general  interest  taken  in 
matters  of  lunacy,  as  also  of  the  development  of  the 
middle  classes  in  England,  and  the  ameliorated  scien- 
tific treatment  of  the  insane,  there  has  gradually  been 
created  by  successive  legislation  an  important  body  of 
functionaries,  to  whom,  in  the  main,  with  the  excep- 
tion of  such  matters  as  I  have  referred  to  above, 
is  entrusted  the  practical  superintendence  of  all 
general  matters  of  lunacy  in  the  country. 

This  body  consists  of  the  Commissioners  in  Lunacy, 
eleven  in  number,  three  of  whom  are  physicians  and 
three  l  barristers,  who  are  remunerated ;  while  the 
remainder,  including  the  permanent  chairman,  are 
unpaid.  Here  let  me  guard  against  a  possible  source  of 
confusion.     That  to  which  I  have  previously  referred 


486     Insanity  and  Allied  Neuroses.    [Chap.  xxiv. 

as  a  commission  in  lunacy  is  not  a  meeting  of  the 
Commissioners  in  Lunacy,  but,  as  I  have  said,  an 
inquiry  into  the  circumstances  of  any  private  case 
instituted  by  the  Masters  in  Lunacy  under  the  Lord 
Chancellor.  The  ambiguity  has  arisen  out  of  the  fact 
that  the  predecessors  of  the  Masters  in  Lunacy,  two 
in  number,  were  called  commissioners,  and  thus  an 
inquiry  instituted  under  their  auspices  came  to  be 
called  a  commission  in  lunacy.  The  growth  of  the 
present  body  of  Commissioners  has  arisen  out  of  a  local 
and  entirely  different  source,  although  they  also  are 
nominally  under  the  Lord  Chancellor's  jurisdiction. 

Formerly  the  College  of  Physicians  was  required 
to  elect  five  fellows  to  act  as  commissioners  for 
licensing  and  inspecting  mad-houses  in  the  imme- 
diate vicinity  of  the  metropolis,  a  similar  function  in 
the  provinces  falling  to  justices  of  the  peace.  Sub- 
sequently their  number  was  increased  to  fifteen,  and 
then,  by  legislation  in  1832,  the  body  was  changed  to 
a  body  styled  the  Metropolitan  Commissioners  in 
Lunacy,  to  whom,  ten  years  later,  was  accorded  the 
duty  of  visiting  the  public  and  private  asylums 
throughout  England  and  Wales.  This  in  its  turn 
was  superseded  in  1845  by  the  present  board  of 
eleven,  the  sphere  of  whose  influence  (as  may  be  seen 
from  the  annual  reports  issued  by  them  in  the  March 
of  each  year)  has  gradually  been  extended  until  there 
are  few  circumstances  in  connection  with  persons  of 
unsound  mind  which  do  not  fall  under  their  imme- 
diate control.  They  have  the  superintendence  of  the 
management  of  all  public  and  private  establishments 
throughout  the  country  for  the  reception  of  the  in- 
sane; they  retain  the  powers  of  granting  licenses  to 
houses  within  their  immediate  jurisdiction,  i.e.  for  the 
metropolis  and  within  a  radius  of  seven  miles ;  they 
may  make  rules  for  their  own  duties  and  those  of  their 
officers  ;  two  of  their  numbej'  in  turn  visit  all  county 


Chap.  XXIV.]    Commissioners  in  Lunacy.  "  487 

and  borough  asylums  and  licensed  houses  at  least  once 
in  every  year,  or  oftener  if  the  occasion  requires  it ; 
they  issue  regulations  concerning  the  admission  of 
patients,  the  keejmig  of  case  books  with  the  necessary 
particulars  concerning  their  illness  by  the  medical 
officers,  the  general  treatment  of  the  insane,  the 
visitation  of  patients  by  properly  qualified  medical 
men  where  there  is  no  resident  physician,  the  admis- 
sion of  friends  of  patients  to  visit  them,  the  reception 
of  special  boarders  in  licensed  houses,  and  the  arrange- 
ment of  chronic  lunatics  in  workhouses.  Copies  of  the 
medical  certificates  of  insanity  have  to  be  forwarded 
for  their  inspection,  as  also  certificates  of  death,  of 
cure,  particulars  concerning  the  escape  and  recapture 
of  patients,  their  removal  from  one  asylum  to  another, 
even  the  change  of  residence  of  any  person  having 
charge  of  a  single  patient,  and  the  notices  of  dismissal 
of  nurses  or  attendants  for  misconduct ;  also  the  ab- 
stracts of  the  accounts  of  the  county  asylums,  and  the 
lists  of  pauper  lunatics,  together  with  a  vast  number  of 
other  particulars.  They  have  the  power  of  ordering 
prosecution  for  non-observance  of  the  regulations 
laid  down  by  them,  of  administering  oaths  and  ex- 
amining witnesses  on  oath  and  directing  expenses  to 
be  paid  to  them,  of  employing  persons  to  make 
inquiries  and  report  on  special  cases. 

Thus  it  will  be  seen  that  the  control  of  nearly  all 
systematic  procedure  in  reference  to  lunatics  through- 
out the  country  falls  within  the  province  of  their  juris- 
diction. And,  indeed,  in  reference  to  those  matters 
falling  more  immediately  under  the  jurisdiction  of  the 
Lord  Chancellor,  the  Lunacy  Commissioners  have  the 
power  of  reporting  to  this  functionary  if  they  have 
reason  to  believe  that  the  property  of  an  alleged  lunatic, 
in  whose  case  no  commission  in  lunacy  has  been  held, 
is  not  properly  protected  or  applied  for  his  benefit, 
which  report  "is  to  be  taken  as  a  petition  for  enquiry." 


488     Insanity  and  Allied  Neuroses.   [Chap.  xxiv. 

These  are  the  main  facts  in  reference  to  the 
government  of  the  insane  as  at  present  adopted  by  the 
higher  branches  of  the  executive.  To  the  duties  of 
magistrates  and  officers  of  minor  importance  I  shall 
have  occasion  to  refer  later,  when  treating  of  the 
different  classes  of  lunatics,  and  the  methods  of  pro- 
cedure adopted  in  reference  to  them. 

Private  lunatics. — By  private  lunatics  I  refer  to 
those  supported  out  of  their  own  property,  who  may 
or  may  not  be  dealt  with  in  Chancery  according  to  the 
determinations  of  a  lunacy  commission,  or  otherwise 
under  the  Lord  Chancellor ;  or  who  may  be  supported 
by  their  friends.  Such  may  be  dealt  with  as  described 
above ;  they  may  be  kept  as  single  patients  in  private 
unlicensed  houses,  or  they  may  be  confined  in  private 
or  public  asylums  or  registered  hospitals  under  orders 
or  medical  certificates,  where  they  are  practically  sub- 
ject to  the  same  regulations  as  the  lunatics  of  other 
classes,  and  to  the  jurisdiction  of  the  Lunacy  Commis- 
sioners. Before  entering  into  any  particulars  concern- 
ing the  places  in  which  they  may  be  confined,  and  the 
regulations  in  connection  with  them  when  they  have 
been  found  insane,  I  will  briefly  describe  the  mode  of  pro- 
cedure adopted  by  commission  or  inquisition  in  lunacy  in 
the  case  of  C^'ancery  lunatics,  who,  though  forming  a 
small  section  of  the  above  group  of  private  lunatics,  so 
far  as  numbers  are  concerned,  may  be  considered  as, 
for  the  most  part,  belonging  to  a  higher  social  class. 

When  any  person  possessed  of  property  is  deemed 
to  be  of  unsound  mind,  and  incapable  of  managing  his 
or  her  affairs,  a  petition  may  be  presented,  by  any  per- 
son interested  in  the  issue  and  willing  to  incur  costs, 
to  the  Lord  Chancellor,  praying  for  an  enquiry  into 
his  or  her  state  of  mind.  The  petition  must  be  sup- 
ported by  the  affidavits  of  two  medical  men,  setting 
fo"th  on  oath  their  opinions  as  to  the  state  of  mind  of 
the  alleged  lunatic,  and  their  reasons  for  holding  such 


Chap.  XXIV.]       Commission  in  Lunacy.  489 

opinions.  These  affidavits  must  be  clearly  drawn  up, 
•with  duly  numbered  paragraphs  ;  they  must  include  a 
full  statement  of  the  qualifications  of  the  medical  man 
himself,  and  must  contain  sufficient  proof  of  his  special 
knowledge  of  insanity.  He  must  set  forth  his  opinions 
with  considerably  greater  detail  than  in  an  ordinary 
medical  certificate,  giving  the  history  of  the  develop- 
ment of  the  symptoms,  his  opinion  as  to  the  issue,  sup- 
plementing his  information  by  facts  which  have  come 
under  his  own  immediate  cognisance ;  in  fine,  every 
collateral  information  must  be  given  which  would 
assist  the  Lord  Chancellor  in  forming  his  decision. 
Should  a  primA  facie  case  be  made  out,  the  Lord 
Chancellor  directs  the  Masters  in  Lunacy  to  hold  an 
enquiry.  A  notice  is  then  sent  to  the  alleged  lunatic, 
if  within  the  jurisdiction,  upon  the  receipt  of  which  he 
is  entitled  to  demand  a  jury,  and  take  measures  for 
his  defence,  except,  indeed,  the  Lord  Chancellor 
should  find  upon  personal  examination,  or  by  his 
representative,  that  he  is  mentally  incompetent  to 
express  a  wish  on  this  head,  in  which  case  the  Lord 
Chancellor  directs  the  Masters  in  Lunacy  to  person- 
ally examine  the  lunatic,  and  investigate  the  facts, 
and  when  they  have  certified  their  finding  thereon 
their  certificates  have  the  same  efiect  as  an  inquisi- 
tion taken  upon  oath  of  a  jury.  This  mode  of  pro- 
ceeding is  also  to  be  adopted  where  the  alleged  lunatic 
does  not  demand  a  jury.  Whether  with  or  without  a 
jury,  the  investigation  must  be  confined  to  the  state  of 
mind  of  the  supposed  lunatic  at  the  time  of  the  en- 
quiry, and  no  evidence  is  allowed  as  to  anything  done 
or  said  by  him  anterior  to  a  period  of  two  years  before 
the  enquiry.  When  the  enquiry  is  held  before  a  jury 
the  verdict  must  be  either  "  that  the  alleged  lunatic  is 
of  sound  mind,  and  capable  of  managing  his  affairs,  or 
that  he  is  of  unsound  mind,  and  incapable."  The 
Masters  in  Lunacy  are  not  entitled  to  accept  a  divided 


49°     Insanity  and  Allied  Neuroses,    [Chap.  xxiv. 

verdict.  I  may  say  here,  however,  that  even  if  he 
were  found  sane  by  inquisition,  I  cannot  see  that  there 
is  anything  to  prevent  him  being  still  confined  under 
the  certificates  of  two  independent  medical  men  just  as 
if  the  inquisition  had  not  been  held.  Such  a  case  would, 
in  the  issue,  be  likely  to  cause  further  litigation. 

The  Lord  Chancellor  has  the  power  of  directing 
the  costs  of  an  inquisition  to  be  paid  either  by  those 
presenting  the  petition,  by  those  opposing  it,  out  of 
the  estate  of  the  alleged  lunatic,  or  partly  in  one  way 
and  partly  in  another.  There  are  many  important 
provisions  with  reference  to  the  management  of  the 
estate  of  Chancery  lunatics  for  which  reference  must 
be  made  to  the  Acts,  or  legal  opinion  must  be  taken. 
A  petition  for  inquisition  should  not,  in  my  opinion, 
be  presented  unless  serious  monetary  interests  are  at 
stake,  as,  in  spite  of  every  judicious  and  graduated 
regulation  of  costs,  the  expense  is  still  very  great ;  in 
fact,  if  such  were  not  proved  to  be  the  case,  as  if  also 
there  were  not  prinid  facie  evidence  of  the  improba- 
bility of  the  lunatic's  cure,  the  Lord  Chancellor  would 
probably  refuse  to  allow  the  enquiry  to  take  place. 
Any  person  desiring  to  traverse  the  inquisition  must 
petition  within  three  months  from  the  date  of  the  re- 
turn. Where  liberty  to  traverse  has  been  applied  for, 
whether  granted  or  not,  the  Lord  Chancellor  may  order 
the  inquisition  to  be  superseded,  with  the  consent  of 
the  lunatic  and  interested  parties,  on  such  terms  and 
conditions  as  he  may  think  proper.  He  possesses  this 
power  even  where  a  traverse  has  not  been  applied  for. 

Should  a  lunatic  be  found  so  by  inquisition,  two  per- 
sons, technically  called  "committees,"  are  appointed  by 
the  Lord  Chancellor,  to  one  of  whom  is  entrusted  the 
care  of  the  person  of  the  lunatic,  and  to  the  other  the 
care  and  management  of  his  property,  both  being  sub- 
ject to  the  control  of  the  Chancery  visitors.  These 
latter  are  bound  to  visit  the  patient  four  times  in  each 


Chap.  XXIV.]       Commission  in  Lunacy.  491 

year,  the  period  between  any  two  visits  not  being 
alloM'^ed  to  exceed  four  montlis,  unless  he  be  conjSned 
in  a  licensed  house,  registered  hospital,  or  asylum,  in 
which  case  he  must  be  visited  once  in  each  year.  The 
visitors  must  report  to  the  Lord  Chancellor  upon 
various  matters  in  connection  with  the  patient's  wel- 
fare ;  their  reports  are  kept  secret,  and  filed,  and  are 
destroyed  upon  the  death  or  recovery  of  the  patient. 

This,  then,  is  the  mode  of  procedure  in  case  of  a 
commission  in  lunacy  being  held.  In  reference  to 
persons  not  found  lunatic  by  inquisition,  who  never- 
theless come  under  the  immediate  jurisdiction  of  the 
Lord  Chancellor,  the  most  important  class  consists  of 
those  where  the  interference  of  the  Lord  Chancellor  is 
desirable  as  regards  the  management  of  the  estate, 
though  it  is  not  required  as  to  the  custody  of  the  per- 
son, and  where  the  estate  is  too  small  to  render  a 
commission  in  lunacy  expedient,  "  In  any  case  of 
this  kind,  if  it  be  established  to  the  satisfaction  of  the 
Lord  Chancellor,  by  report  of  one  of  the  Masters  in 
Lunacy,  or  by  the  report  of  the  Commissioners  in 
Lunacy,  or  by  affidavit  or  otherwise,  that  the  person 
in  question  is  of  unsound  mind  and  incapable  of 
managing  his  affairs,  and  that  his  property  does  not 
exceed  .£2,000  in  value  or  £100  in  yearly  income,  the 
Lord  Chancellor  may,  without  directing  any  enquiry 
under  a  commission  in  lunacy,  but  after  giving  due 
notice  to  the  alleged  lunatic,  make  an  order  for  ren- 
dering the  property,  or  the  income,  available  for 
maintenance  or  benefit,  or  for  carrying  on  his  trade  or 
business."  The  Lord  Chancellor  also,  with  the  help  of 
the  Masters  in  Lunacy,  may  take  what  specific  mea- 
sures he  deems  expedient  for  the  furthering  of  these 
purposes.  Similar  powers  are  given  to  the  Lord 
Chancellor  with  regard  to  persons  acquitted  from  any 
criminal  accusation  on  the  ground  of  lunacy. 

Before  leaving  this  subject,  it  is  desirable  that  I 


492     Insanity  and  Allied  Neuroses.   [Chap.  xxiv. 

should  specify  the  considerations  by  which  medical 
men  should  be  guided  in  recommending  patients  to  be 
made  wards  of  the  Court  of  Chancery.  The  most  im- 
portant case  is  when  serious  money  interests  are  at 
stake,  as  I  have  described  above.  It  must  be  fully 
understood  that  a  person  of  unsound  mind  can  transact 
business  imless  he  has  been  placed  under  certificates  ; 
so  that  a  person,  although  acknowledged  by  his  friends 
to  be  a  lunatic,  can  sign  cheques  and  make  a  will,  and 
squander  his  property  without  let  or  hindrance,  unless 
he  is  made  a  lunatic  by  inquisition,  or  unless  he  is 
under  certificates.  An  injunction  is  the  best  method 
of  preventing  money  being  obtained  while  steps  are 
being  taken  to  certify  that  the  patient  is  of  unsound 
mind.  An  injunction  can  readily  be  obtained  by  the 
solicitor,  supported  by  the  medical  affidavits,  in  the 
manner  I  have  described  above ;  and  if  the  property 
be  certified  under  the  amount  named,  and  the  two 
medical  affidavits  be  found  satisfactory,  application 
will  be  followed  by  an  order  of  the  court  appointing 
the  "  committee  "  of  the  person  and  of  the  estate. 

It  must  be  observed  that  no  person  under  certifi- 
cates can  legally  transact  any  business,  and  whoever 
has  charge  of  lunatics  in  private  or  public  must  re- 
member that  it  is  his  duty  to  prevent  any  business 
being  done. 

Having  now  noticed  the  chief  points  in  connection 
with  inquisition  in  lunacy,  I  shall  pass  on  to  consider 
circumstances  in  connection  with  private  lunatics.  I 
may  first  just  remark,  that  though  a  certain  number  of 
persons  become  lunatic  in  the  eye  of  the  law  in  this 
manner,  by  far  the  greater  number  come  under  the  cog- 
nisance of  the  law  by  being  confined  in  public  or  private 
asylums,  on  the  strength  of  the  certificates  of  medical 
men,  where  they  are  then  provided  for  by  the  law 
under  the  regulations  of  the  Lunacy  Commissioners. 

Private  lunatics,  whether  found  so  by  inquisition 


Chap.  XXIV.]  FrIVATE    CONFINEMENT.  493 

or  otherwise,  may  be  taken  care  of  by  their  friends  ; 
they  may  be  confined  as  single  patients  in  unlicensed 
houses,  or  in  registered  hospitals  or  licensed  houses,  or 
in  county  and  borough  asylums. 

In  the  first  place,  in  reference  to  any  lunatic  who 
may  be  confined  'privately  in  the  house  of  some  rela- 
tive or  friend,  or  other  person  deriving  no  profit  from 
the  charge,  the  only  cognisance  taken  by  the  law  is 
that  "  it  is  lawful  for  the  Lord  Chancellor  or  the  Home 
Secretary  at  any  time  by  an  order  in  writing  under  his 
hand  directed  to  the  Commissioners  in  Lunacy,  or  any 
of  them,  or  to  any  other  person,  to  require  the  person 
or  persons  to  whom  the  order  is  directed,  or  any  of 
them,  to  visit  and  examine  the  lunatic,  and  report 
upon  the  subject." 

With  regard  to  the  subject  of  the  ill-treatment  of 
private  lunatics  in  the  charge  of  their  friends,  for 
which  some  provision  is  now  made  by  the  law,  it  ap- 
pears that  during  the  early  part  of  this  century  the 
law  was  very  imperfectly  laid  down  on  this  head, 
that  decisions  were  unintelligibly  conflicting,  and  that 
many  perpetrators  of  ill-treatment  escaped  in  conse- 
quence of  there  being  no  technical  possibility  of  re- 
warding them  with  the  punishment  they  deserved.  In 
their  eighth  annual  report,  however  (1854),  the  Com- 
missioners in  Lunacy  mention  the  case  of  one  Evan 
Roberts,  who  was  confined,  first  by  his  father,  and  after 
his  father's  death  by  his  brother,  in  a  small  room, 
chained  to  the  bedstead,  and  otherwise  neglected  and 
ill-treated.  In  this  case  Lord  Campbell,  who  charged 
the  jury,  distinctly  laid  it  down,  "  that  the  use  of  re- 
straint, greater  in  degree,  more  severe  in  character,  or 
longer  in  duration  than  is  necessary  for  the  security 
and  care  of  a  lunatic,  is  an  offence  at  common  law 
punishable  by  indictment."  There  was  also  about  this 
time  the  case  of  Charles  Luxmore,  a  lunatic,  the  son 
of  a  small  farmer  in  Devonshire,  who  suffered  similar 


494     Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

ill-treatment  at  the  hands  of  a  brother-in-law,  the 
latter  being  found  guilty  and  sentenced  to  six  months' 
imprisonment. 

Some  difficulties  have  arisen  in  respect  of  such  re- 
lationships as  a  wife  under  the  care  of  her  husband, 
or  a  child  of  its  parents,  it  having  been  held  that 
"  the  section  only  applies  to  such  persons  as  have  the 
charge  and  care  of  lunatics  otherwise  than  in  conse- 
quence of  natural  obligation  arising  from  the  relation 
of  husband  and  wife  or  parent  and  child."  For  in- 
stance, in  1872,  a  son  (alleged  to  be  illegitimate)  was 
indicted  for  neglect  and  ill-treatment  of  his  lunatic 
mother;  but  the  Court  held  that  "  having  regard  to  his 
relationship  with  the  lunatic  the  Act  did  not  apply." 
In  connection  with  this  case  the  Commissioners  re- 
marked in  their  next  report  "  that  they  thought  it 
unfortunate  that  the  court  did  not  reserve  the  point  of 
law,"  and  there  can  be  no  doubt  that  this  is  one  of  the 
points  on  which,  even  at  the  present  time,  a  modifica- 
tion of  the  law  is  much  to  be  desired.  Looking,  how- 
ever, at  the  circumspection  exercised  by  the  Lunacy 
Commissioners,  I  strongly  recommend  all  persons, 
whether  in  the  medical  profession  or  otherwise,  to  be 
extremely  careful  how  they  act  in  connection  with  per- 
sons of  unsound  mind,  even  with  the  best  intentions. 

If  the  lunatic  be  received  to  board  and  lodge  in  the 
house  of  any  one  compensated  by  pecuniary  remunera- 
tion, although  this  house  come  under  the  designation  of 
unlicensed  houses,  it  is  under  the  superintendence  of 
the  Commissioners  in  Lunacy,  and  their  regulations 
are  most  stringent.  No  person  can  be  received  into 
such  a  house  without  an  order  and  two  medical  certifi- 
cates (except  by  an  order  of  the  "  committee  "  in  the 
case  of  persons  found  lunatic  by  inquisition).  In  this 
case,  as  also  in  the  case  of  other  kinds  of  establish- 
ments, the  order  must  be  signed  by  some  person  who 
has  seen  the  patient  within  one  month  of  the  time  of 


Chap.  XXIV.]  Private  Asylums,  495 

his  reception  into  the  asylum.  Though  the  Commis- 
sioners request  that,  as  a  general  rule,  some  near 
relation  should  sign  the  order,  this  is  not  absolutely 
necessary.  A  stranger  may  sign  it,  and  in  some  cases 
it  is  desirable  that  the  nearest  relation  should  not  do 
so.  Thus  in  some  acute  curable  cases,  especially  those 
in  which  drink  has  had  a  share  in  the  production  of 
the  symptoms,  if  the  wife  sign  the  order,  the  husband, 
on  recovery,  may  be  enraged  at  the  part  she  took,  and 
further  trouble  may  arise.  Copies  of  the  order  and 
certificates  must  be  immediately  forwarded  to  the 
Commissioners ;  also  a  statement  of  the  patient's 
health,  more  than  two  and  less  than  seven  days  after 
his  reception  ;  the  patient  must  be  visited  by  a  phy- 
sician unconnected  with  him  or  with  those  having  charge 
of  him  ;  a  "medical  visitation  book  "  is  to  be  kept,  with 
accurate  records  of  the  patient's  health,  accessible  to 
the  Commissioners  when  they  visit  the  establishment ; 
notice  must  be  forwarded  in  case  of  death,  discharge, 
removal,  escape  and  recapture,  or  change  of  residence. 
For  all  these  matters  stereotyped  forms  are  prepared, 
and  must  be  strictly  filled  in  and  adhered  to  ;  any 
lapse,  especially  in  the  way  of  neglect  or  ill-treatment, 
being  followed  by  indictment  for  misdemeanour  or  the 
penalty  of  a  fine. 

We  come  now  to  licensed  houses  or  private  asy- 
lums, which  often  present  many  advantages.  They  are 
under  the  personal  control  and  management  of  a  pro- 
prietor or  superintendent,  and  are  not  hampered  by 
the  general  regulations  pertaining  to  the  larger  establish- 
ments. Naturally  more  liberty  can  be  allowed  to  the 
patient,  and  greater  facility  for  the  visits  of  friends. 
The  arrangements  are  often  similar  to  those  of  a 
private  family,  and  aflTord  a  greater  degree  of  privacy, 
together  with  the  necessarj'-  safeguards  of  the  larger 
establishments.  The  license  for  these  establishments  is 
granted  by  the  Lord  Chancellor  within  the  immediate 


496     Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

jurisdiction,  viz.  for  the  metropolis  and  within  a  radius 
of  seven  miles  \  in  the  provinces  by  the  county  or 
borough  justices  at  quarter  sessions.  The  holder  of 
the  licence  must  reside  on  the  premises  licensed,  and 
the  resident  physician  or  medical  attendant  must  be 
approved  by  the  Commissioners.  Licences  are  fre- 
quently held  by  members  of  the  medical  profession  j; 
but  they  may  be  held  by  ordinary  persons,  or  by  ladies 
for  the  reception  of  female  lunatics.  The  most  stringent 
inquiry  is  instituted  as  to  the  personal  fitness  of  the 
applicant  for  such  a  post,  his  or  her  social  condition, 
and  by  vs^hom  pecuniary  emolument  will  be  derived  ; 
particulars  must  be  given  as  to  payments,  etc.;  in- 
quiry is  also  made  as  to  the  structural  adaptation  of  the 
establishment  to  be  licensed.  In  the  case  of  a  medical 
applicant,  he  must  state  full  particulars  concerning  his 
general  and  professional  education,  his  degree,  where 
and  in  what  manner  he  has  acquired  his  experience  in 
lunacy ;  he  must  produce  satisfactory  testimonials  as 
to  his  medical  skill  and  his  personal  fitness  to  be 
entrusted  with  the  care  of  the  insane  ;  he  must  be  pos- 
sessed of  adequate  pecuniary  means,  besides  other 
matters.  The  licence  is  usually  granted  "for  such 
period  not  exceeding  thirteen  calendar  months  as  to 
the  Commissioners  may  seem  fit ; "  but  I  may  say 
that  the  Commissioners  have  determined  not  to  in- 
crease the  number  of  licensed  houses  within  the  metro- 
politan area  except  under  exceptional  circumstances. 

In  boroughs,  the  consent  of  the  recorder,  in  writing, 
is  also  required  ;  and  the  applicant  forwards  his  appli- 
cation to  the  clerk  of  the  peace,  as  also  to  the  Com- 
missioners, who  must  first  inspect  the  premises,  and 
report  to  the.  justices  before  the  latter  can  entertain 
the  proposal,  which  is  almost  invariably  decided  in 
accordance  with  their  recommendation.  A  copy  of 
the  licence,  when  granted,  must  be  forwarded  to  the 
Commissioners.     Licensed  houses  having  a  hundred  or 


Chap.  XXIV.]       Registered  Hospitals.  497 

more  patients,  are  compelled  to  have  a  resident 
medical  superintendent;  those  with  under  a  hundred 
and  over  fifty  must  be  visited  daily  by  a  medical  atten- 
dant ;  where  there  are  less  than  fifty,  twice  a  week. 

We  now  come  to  registered  hospitals.  In  1815 
there  were  nine  such  institutions  in  existence,  now  * 
(1884)  there  are  sixteen.  Registered  hospitals  for 
the  reception  of  lunatic  patients  differ  little  in  their 
constitution  and  management  from  ordinary  hospitals. 
They  are  generally  under  the  control  of  a  committee, 
consisting  of  elected  and  ex-officio  members,  and  are 
supported  by  endowment  or  by  annual  contribution. 
Copies  of  the  regulations  concerning  their  management 
must  be  approved  by  the  Secretary  of  State  and  sent 
to  the  Lunacy  Commissioners.  For  the  most  part 
they  have  the  same  relation  to  the  lunacy  laws  as 
licensed  houses.  Every  hospital  must  be  registered, 
and  is  required  to  have  a  resident  physician,  surgeon, 
or  apothecary,  as  the  superintendent  and  medical 
supervisor.  So  far  as  the  social  class  of  the  patients 
is  concerned,  speaking  generally,  these  institutions 
occupy  a  position  midway  between  the  ordinary  pri- 
vate asylums  and  the  county  asylums  for  paupers  (to 
which  we  shall  come  presently).  The  Commissioners 
in  Lunacy  strongly  recommend  the  extension  of  hos- 
pital accommodation  for  the  insane  poor,  who,  although 
not  paupers,  are  unable,  nevertheless,  to  afford  the 
expense  incurred  in.  a  private  asylum.  Their  recom- 
mendation is  also  to  be  supported  from  the  fact  that 
there  are  a  large  number  of  mild  and  curable  cases 
occurring  nowadays  among  a  class  such  as  governesses 
and  clerks,  either  without  resources  or  whose  resources 
are  too  slight  to  bear  the  cost  of  a  serious  illness.  To 
such  it  would  be  a  social  indignity  to  ])e  relegated 
to  a  pauper  asylum,  but  they  are  able  and  willing 
to  avail  themselves  of  the  benefit  afibrded  by  the 
*  See  Appendix. 
G  G 14 


498     Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

treatmenfc  in  a  hospital.  Formerly  there  were  too 
few  of  these  refuges  of  a  charitable  nature  for  the 
insane. 

In  connection  with  these  institutions  an  interesting 
question  arose  a  few  years  ago,  as  to  whether  persons 
not  being  actually  insane,  but  conscious  of  a  loss  of  self- 
control  (owing  to  alcohol  or  other  causes),  or  liable  to 
fits  of  recurrent  insanity,  could  be  received  into  them 
as  voluntary  boarders.  The  Commissioners  laid  the 
case  before  counsel,  and  the  opinion  given  was  "  that 
there  appears  to  be  nothing  in  the  statutes  to  prevent 
the  admission  of  the  persons  referred  to  as  voluntary 
boarders  into  registered  hospitals,  and  that  there  would 
apparently  be  no  difficulty  in  enforcing  legally  the 
stipulations  and  conditions  of  any  agreement  by  bond 
or  otherwise  for  their  residence  therein."  A  provision 
somewhat  analogous  to  the  foregoing  is  made  (and 
applies  both  to  hospitals  and  licensed  and  unlicensed 
houses)  by  the  sixth  section  of  the  Act  16  &  17 
Vict.,  c.  96,  as  follows :  "  That  it  shall  be  lawful  for 
the  proprietor  or  superintendent  of  any  licensed  house, 
with  the  previous  assent  in  writing  of  two  of  the  Com- 
missioners, to  entertain  and  keep  in  such  house,  as  a 
boarder,  any  person  who  may  have  been  discharged  as 
a  patient  from  such  house,  for  such  time  after  such 
discharge  as  he  may  desire  to  remain,  not  exceeding 
the  time  specified  in  such  assent."  No  fresh  orders  or 
certificates  are  required  in  these  cases,  A  personal 
examination  by  the  Commissioners  is  necessary,  how- 
ever, in  order  that  they  may  be  assured  that  it  is  by 
the  desire  of  the  patient  that  he  so  remains.  A  friend 
or  relation  of  the  patient  may  also  be  allowed  to  re- 
main as  his  companion  during  the  time  specified  by 
the  Commissioners,  which  they  have  the  power  to 
terminate  when  it  shall  seem  fit  to  them. 

Legal  opinion  has  been  taken  to  the  effect  that 
such  persons  are  themselves  capable  of  contracting  to 


CTiap.  XXIV.]       Medical   Certificates.  499 

observe    the    regulations  of  the  house  or  hospital  in 
which  they  desire  to  remain. 

I  have  spoken  of  the  signing  of  medical  certificates 
in  connection  with  the  reception  of  private  lunatics 
into  hospitals  and  licensed  houses,  and  I  shall  have 
occasion  to  refer  to  them  again  when  treating  of 
pauper  lunatics  :  although  certificates  of  this  class  are 
not  of  the  voluminous  nature  required  by  the  Lord 
Chancellor  in  case  of  inquisition  in  lunacy,  certain 
forms  are  laid  down  with  regard  to  them  which  are  of 
the  last  importance  both  to  medical  men  and  to  all 
concerned.  In  the  case  of  private  lunatics  we  have 
seen  that  two  certificates  were  required.  These  must 
be  signed  by  properly  qualified  medical  men  (one  being 
a  registered  physician,  surgeon,  or  apothecary)  "  duly 
authorised  or  licensed  to  practise  as  such,  by  or  as  a 
member  of  some  college,  university,  company,  or  insti- 
tution legally  established  and  qualified  to  grant  such 
authority  or  license  in  some  part  of  the  United  King- 
dom." They  must  have  no  connection  with  the  person 
to  whose  care  the  lunatic  is  to  be  transmitted  ;  they 
must  not  be  in  partnership  one  with  another,  nor 
may  they  be  related  to  the  person  who  signs  the 
order.  I  must  strongly  insist  upon  the  gravity  of 
this  important  subject,  and  warn  my  fellow-prac- 
titioners that  the  law  is  most  stringent  in  res[)ect 
to  the  regulations  it  has  laid  down.  The  Christian 
and  surnames  of  the  patient  must  be  written  in  full, 
together  with  the  proper  address  and  occupation,  if  any. 
The  certificate  must  state  the  facts  observed  by  the 
doctor,  and  those  communicated  by  others,  from  which 
the  conclusion  of  insanity  has  been  deduced.  The  cer- 
tificate is  valid  for  seven  clear  days  only,  and  if  the 
patient  be  not  removed  to  the  asylum  before  the 
expiry  of  that  date,  fresh  certificates  (unless  the  old 
ones  can  be  re-dated  with  propriety)  are  required.  No 
patient    can    be    received   into    an    asylum    upon   the 


500      Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

strength  only  of  facts  communicated  by  others  to  the 
medical  man  who  signed  the  certificate.  A  separate 
examination  is  necessary.  In  exceptional  cases,  how- 
ever, where  a  statement  accompanying  the  order  for 
admission  is  sent,  describing  circumstances  which 
render  it  impossible  for  two  certificates  to  be  procured 
(as,  for  instance,  in  the  case  of  a  dangerous  lunatic), 
the  patient  may  be  sometimes  admitted  on  one  certi- 
ficate, but  within  three  clear  days  two  other  such 
certificates  must  be  duly  furnished  fulfilling  the  pre- 
ceding conditions,  or  those  conniving  at  the  detention 
of  the  patient  are  "guilty  of  misdemeanour." 

So  particular  are  the  Commissioners,  to  whom  these 
certificates  are  sent,  that  they  ordered  the  liberation 
of  one  patient  on  the  ground  that  the  certificate  was 
invalid,  because  it  did  not  contain  the  number  of 
the  house  in  which  he  had  lived ;  again,  in  another 
case,  because  the  medical  men  signed  certificates,  not 
from  what  they  observed  on  any  particular  day,  but 
from  what  was  known  to  them  in  consequence  of 
having  attended  the  patient  during  a  considerable 
period  of  time ;  and  yet  in  another,  when  it  was  found 
that  the  medical  man  had  signed  a  certificate  six  weeks 
prior  to  the  admission  of  the  patient,  the  Commis- 
sioners wrote  to  the  proprietor  that  they  considered 
his  negligence  "  a  most  grave  ofience." 

Medical  men  may  be  fined  £20  for  signing  cer- 
tificates without  due  observance  of  the  regulations,  or 
if  falsity  be  suspected,  they  may  be  indicted  for  mis- 
demeanour. They  are  also  liable  to  action  on  the  part 
of  the  patient  himself,  and  in  a  case  of  which  I  have 
the  particulars  before  me,  .£150  damages  were 
recovered,  the  charge  being  that  Dr. "  had  neg- 
ligently and  culpably  failed  duly  to  enquire  into  the 
truth  of  the  facts." 

In  connection  with  these  facts  it  should  not  be 
forgotten  that  a  power  is  given  to  the  medical  man 


Chap.  XXIV.]       Medical  Certificates.  501 

which  no  other  functionary  in  the  land  possesses, 
namely,  the  deprivation  of  a  subject,  not  merely 
of  his  liberty,  but  of  his  civil,  social,  financial,  po- 
litical, and  even  of  his  domestic  rights. 

Copies  of  the  certificates  have  to  be  sent  to  the 
Commissioners  in  Lunacy,  and  must  be  inspected  by 
the  visiting  commissioners  when  they  go  their  rounds ; 
theoretically  they  have  no  legal  value  until  they  have 
been  thus  vised  by  the  authorities.  The  following, 
however,  is  important  :  "If,  after  the  reception  of  any 
lunatic,  it  appears  that  the  order  or  medical  certificate, 
or  (if  more  than  one)  both  or  either  of  the  medical 
certificates  upon  which  he  was  received  is  or  are  in 
any  respect  incorrect  or  defective,  such  order  and 
medical  certificate,  or  certificates,  may  be  amended  by 
the  person  signing  the  same,  at  any  time  within 
fourteen  days  next  after  the  reception  of  such  lunatic; 
provided,  nevertheless,  that  no  such  amendment  shall 
have  any  force  or  efiect  unless  the  same  shall  receive 
the  sanction  of  one  or  more  of  the  commissioners.^'  I 
strongly  recommend  medical  men,  in  all  important 
cases,  to  keep  a  copy  of  the  certificates  they  issue,  as 
circumstances  may  arise  rendering  it  desirable  for 
them  to  have  at  hand  some  particulars  concerning  the 
facts  and  reasons  which  guided  them  at  the  time  in 
certifying  the  insanity. 

The  Commissioners  point  out  that  "  few  of  our 
duties  require  more  vigilance  than  that  of  satisfying 
ourselves,  in  all  doubtful  cases,  as  to  the  validity  of 
the  orders  and  certificates  on  which  patients  are 
admitted  into  asylums,  or  become  subject  to  detention 
in  any  place."  Complaints  of  the  negligence  of 
medical  men,  and  their  disregard  of  the  marginal 
directions,  are  frequent,  "The  object  of  all  these 
precautions,"  say  the  Commissioners,  "is  to  provide 
that  no  one  shall  be  deprived  of  his  liberty  as  a  person 
of  unsound  mind,  except  upon  specific  grounds  existing 


502      Insanity  and  Allied  Neuroses.  [Cbap.  xxiv. 

at  the  exact  time  when  it  is  proposed  to  place  him 
"imder  restraint." 

Apart  from  the  purely  legal  restrictions  in  con- 
nection with  medical  certificates,  there  are  one  or  two 
general  matters  to  which  I  may  as  well  refer. 

It  is  incumbent  upon  a  medical  man,  in  signing  a 
certificate,  to  consider  not  only  the  question  of  the 
insanity,  but  whether  the  patient  is,  or  is  not,  a  fit 
subject  to  be  detained  under  restraint,  and  what 
benefit  he  is  likely  to  derive  from  the  peculiar  form  of 
treatment  it  is  proposed  to  subject  him  to.  It  is 
practically  impossible  to  lay  down  any  general  rules 
for  guidance  in  this  diflQcult  matter,  as  almost  every 
case  presents  some  individual  peculiarity ;  the  medical 
practitioner  must  be  guided  by  his  own  experience 
and  tact.  Perhaps  the  form  of  insanity  offering  the 
most  obstacles  to  due  certification  is  that  of  delu- 
sional insanity.  "Madmen,"  says  Dr.  Blandford, 
"have  an  unpleasant  way  of  revealing  family  secrets, 
and  it  is  convenient  to  call  all  such  revelations 
delusions.  Here  you  must,  if  possible^  derive  informa- 
tion from  others  who  are  not  primarily  concerned,  old 
servants,  medical  men,  acquaintances,  and  the  like. 
But  for  them  I  should  certainly  have  been  disposed  to 
accept  as  delusions  some  of  the  facts  that  have  been 
told  me  by  patients,  and  even  now  I  am  in  doubt 
about  some,  never  having  been  able  to  arrive  at  the 
truth."  Undoubtedly  this  is  good  advice,  but  the 
medical  man  must  be  sure  to  give  his  own  reasons  also 
for  coming  to  his  conclusion.  What  is  wanted  is 
logical  and  consistent  prima  facie  proof  of  the  patient's 
fitness  to  be  placed  under  restraint.  Hearsay  evidence 
should  not  be  entered  without  its  being  stated  to  be 
sucli,  nor  should  any  statement  be  made  which  cannot 
be  verified  upon  oath  in  a  court  of  justice.  The 
doctor  who  signs  the  certificate  should  always  bear 
in  mind  the  responsibility  he  incurs. 


Chap.  XXIV.]    Restraint  in  Delirium.  503 

Perhaps  one  of  the  most  difficult  matters  in  con- 
nection with  the  signing  of  certificates,  has  proved 
to  be  the  placing  under  restraint  of  persons  suffer- 
ing from  the  delirious  loss  of  control  resulting  from 
the  misuse  of  alcohol.  The  late  Baron  Bramwell, 
in  a  case  brought  before  him  at  the  Surrey  summer 
assizes  in  1862,  in  which  an  action  for  trespass 
was  brought  against  a  medical  man  for  placing  the 
plaintiff,  who  was  suffering  from  deliritmi  tremenSj 
under  restraint,  held  that  "  at  common  law  and 
apart  from  the  lunacy  statutes,  a  medical  man  may 
justify  measures  necessary  to  restrain  a  dangerous 
lunatic,  and  that  if  he  be  called  in  to  attend  a  person 
suffering  under  delirium  tremens,  he  may  justify  such 
measures  as  are  reasonably  necessary,  either  to  cure 
the  person  so  suffering,  or  to  restrain  him  from  doing 
mischief  so  long  as  the  fit  lasts,  or  is  likely  to 
return."  In  the  case  of  a  widow  in  1863,  with  whom 
restraint  had  been  used  for  what  the  medical  men  held 
to  be  delirium  tremens,  but  which  she  denied,  the 
Lord  Chief  Justice  remarked  in  his  summing  up, 
"that  there  had,  no  doubt,  been  some  restraint  upon 
natural  personal  liberty,  but  was  it  not  necessary  1 
Let  the  jury  put  themselves  in  the  position  of  these 
gentlemen,  or  of  the  friends  and  relatives  of  this 
person  (the  plaintiff),  and  let  them  ask  whether,  even 
supposing  that  the  defendants  were  responsible  for  all 
that  had  been  done  to  prevent  her  from  getting  out 
into  the  streets  or  throwing  herself  out  of  the  window, 
the  jury  would  not  consider  that  these  gentlemen,  so 
far  from  being  proper  subjects  of  condemnation  and  of 
censure,  were  not  rather  fit  objects  of  gratitude  and 
regard."  The  Lord  Chief  Justice  further  deprecated 
"exposing  medical  men  unjustly  to  vexatious  and 
harassing  actions." 

In  another  case,  however,  the  family  of  a  certain 
individual,    not    a    pauper,    made    complaint  to    the 


504      Insanity  AND  Allied  Neuroses.  [Chap.xxiv. 

relieving  oflEicer  of  his  violent  conduct ;  this  officer 
caused  him  to  be  conveyed  to  the  lunatic  ward  of  the 
Lambeth  workhouse  upon  a  single  medical  certificate, 
to  the  effect  that  he  was  of  unsound  mind  aggravated 
by  drink,  and  wholly  unfit  to  be  at  large  ;  that  his 
conduct,  both  at  home  as  well  as  abroad,  was  out- 
rageous, and  that  he  was  continually  threatening  his 
own  life  and  that  of  his  children."  In  a  few  days  this 
person  recovered  from  the  effects  of  his  intemperance, 
and  subsequently  brought  an  action  against  the  reliev- 
ing oflS.cer.  Mr.  Justice  Byles,  in  summing  up  the 
case,  credited  this  functionary  with  having  "  acted  as 
he  believed  it  to  be  his  duty  to  do,  but  as  he  had  not 
obtained  the  certificates  required  by  the  statute,  he 
was  legally  wrong,  and  a  verdict  must  go  against  him." 
The  jury  thereupon  found  for  £20  damages,  and  their 
verdict  was  subsequently  confirmed  upon  appeal  being 
made.  In  this  case  we  have  an  illustration  of  both 
sides  of  the  question. 

Dr.  Clouston,  also,  in  his  recent  work,  urges  "  that 
in  cases  where  the  attack  is  likely  to  last  for  any 
length  of  time,  patients  suffering  from  delirium  tremens 
should,  in  the  ordinary  course,  be  sent  to  an  asylum, 
or  registered  hospital,  as  these  institutions  possess  the 
requisite  facility  for  their  treatment,  such,  as  could  not 
be  commanded  at  the  patient's  own  home  or  at  an 
ordinary  hospital."  In  this  I  entirely  concur,  and  I 
cannot  but  think  that  if  the  treatment,  which  is 
available,  and  which  is  by  no  means  a  heavy  expense 
in  these  temporary  cases,  were  sought  oftener  than  it 
is  at  present,  much  brutality  and  crime  might  be  pre- 
vented. There  is  no  sight  more  salutary  to  those  who 
are  the  slaves  of  some  noxious  habit,  than  to  be  thrown 
for  a  short  time  among  the  surroundings  of  disease 
and  loathsomeness  which  are  its  worst  results,  where 
they  have  ample  time  both  for  observation  and  reflec- 
tion.    Though  a   permanent  re-establishment  of   the 


Chap. XXIV.]  Regulations  of  Commissioners.     505 

perverted  will  should  be  impossible,  an  influence  may- 
be awakened  whicb  will  go  far  to  counteract  the 
baneful  tendency  for  the  future,  and  will,  at  any  rate, 
avert  evil  consequences  at  the  time  of  the  attack. 

A  great  deal  has  doubtless  been  done  for  the 
treatment  of  those  who  develop  the  mania  of  alcohol, 
by  the  establishment  of  the  licensed  "  retreats  "  for 
habitual  drunkards;  and  the  state  having  recognised 
the  divergence  of  this  subject  from  the  subject  of 
insanity^  has  provided,  by  the  ninth  section  of  the 
habitual  drunkards  Act  of  1879,  that  "no  licence 
shall  be  given  to  any  person  (for  one  of  these 
'retreats')  who  is  licensed  to  keep  a  house  for  the 
reception  of  lunatics." 

The  above  remarks  will  also  suggest  the  course 
often  to  be  pursued  in  the  case  of  lunatics  who  may 
be  dangerous  to  themselves  or  others,  from  other 
causes  than  alcohol. 

Finally,  in  reference  to  the  subject  of  certificates, 
I  would  recommend  those  who  have  to  certify,  to  avoid 
the  use  of  all  vague  terms  such  as  "  excitement," 
"bad  temper,"  "emotional,"  and  the  like;  and,  if 
possible,  in  obtaining  these  particulars  to  abstain 
from  all  strategy  and  underhand  procedure,  as  the 
discovery  of  such  may  have  a  most  injurious  effect 
upon  the  course  of  the  patient's  illness.  It  is  better 
to  be  straightforward  and  open,  as  it  will  then 
be  found  much  easier  to  obtain  the  patient's  con- 
fidence, and  this  having  been  obtained,  there  will  be 
little  further  difficulty  in  discovering  the  suspected 
hallucination  or  delusion.  This  is  but  the  illustration 
of  a  general  principle  to  be  adopted  in  the  treatment 
of  the  insane. 

There  are  a  vast  number  of  regulations  of  the  Com- 
missioners in  reference  to  circumstances  which  may 
arise  in  connection  with  the  restraint  of  lunatics,  to 
the  most  important  of  which  it  will  be  better  that  I 


5o6      Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

should  refer,  after  having  treated  of  pauper  lunatics 
and  county  asylums,  as  many  of  their  provisions 
apply  equally  to  these  as  to  the  other  classes  I  have 
already  described.  I  may  here,  however,  refer  to  the 
system  of  visitation  adopted  with  regard  to  registered 
hospitals  and  licensed  houses. 

All  registered  liospitals,  wherever  situated,  and  all 
licensed  houses  "  within  the  immediate  jurisdiction," 
ai'e  placed  under  the  supervision  of  the  Commissioners 
in  Lunacy  ;  while  licensed  houses  beyond  the  immediate 
jurisdiction  are  under  the  supervision  of  visiting 
justices,  though  also  of  the  Commissioners  in  Lunacy. 

Every  hospital  must  be  visited  by  two  of  the  Com- 
missioners, one  being  a  barrister  and  the  other  a  doctor, 
twice  a  year,  without  notice  being  given  ;  if  the  licensed 
house  be  within  the  immediate  jurisdiction,  four  times 
a  year,  except  a  special  representation  be  made  to  the 
Lord  Chancellor  by  the  Commissioners,  when  the  Lord 
Chancellor  may  direct  that  "  any  house  licensed  by 
them,  and  not  receiving  pauper  patients,  shall  be 
visited  twice  only  in  the  year."  The  duties  of  the 
Commissioners  with  regard  to  such  visits  are  strictly 
laid  down.  It  is  incumbent  upon  them  "  to  inspect 
the  whole  of  the  premises,  to  see  every  patient,  to  as- 
certain whether  any  patient  is  under  restraint,  and  if 
so,  why  ;  to  inspect  the  orders  of  admission  and  medi- 
cal certificates,  and  in  certain  cases  the  license  as  well 
as  the  books  required  to  be  kept  and  other  documents. 
They  are  also  to  enquire  as  to  Divine  service,  the 
occupations  or  amusements  of  the  patients  ;  the  system 
of  treatment  and  other  matters ;  and  to  enter  the 
result  of  their  inspection  and  enquiries  in  the  visitors' 
book,  and  any  remark  they  may  think  fit  to  make  in 
the  patients'  book."  Copies  of  such  entries  by  the 
visiting  commissioners  must  be  forwarded  to  the  Com- 
missioners within  three  days  of  the  visit  by  the  medi- 
cal superintendent,   upon   whom   falls    the   obligation 


Chap.  XXIV.]  Visitation  System.  507 

of  affording  the  commissioners  every  facility  in  the 
pursuit  of  their  enquiry.  The  visiting  commissioners 
also  themselves  report  to  the  Commissioners  on  the 
subject  of  their  visits,  and  such  reports  are  pre- 
served by  the  secretary.  They  have  the  option  of 
paying  such  visits  not  only  according  to  the  prescribed 
intervals  of  time,  but  at  such  hour  of  the  day  or  night 
as  they  think  fit,  in  fact,  at  any  time. 

With  regard  to  licensed  houses  beyond  the  metro- 
politan jurisdiction,  it  is  provided  "that  visitors  shall 
be  appointed  in  any  county  or  borough  at  the  Michael- 
mas quarter  sessions  in  every  year  (but  in  boroughs 
with  the  consent  of  the  recorder),  consisting  of  three 
or  more  justices,  VT'ho  are  to  act  gratuitously,  and  one 
(or  more)  physician,  surgeon,  or  apothecary,  who  is  to 
be  remunerated  .  .  .  but  no  person  interested 
in  a  licensed  house  can  act  as  visitor,  clerk,  or  as- 
sistant clerk."  The  provisions  laid  down  vdth  regard 
to  their  visits  are  similar  to  those  in  respect  of  the 
visiting  commissioners.  Two  at  least  of  the  visitors 
(one  being  a  physician,  surgeon,  or  apothecary),  are  to 
visit  each  licensed  house  within  their  jurisdiction  four 
times  a  year  at  least,  and  at  such  other  times  as  the 
justices  may  direct ;  and,  in  addition,  each  house  may 
be  visited  at  any  time.  The  visits  are  paid  without 
previous  notice,  and  care  is  taken  that  no  proprietor 
has  fore-knowledge  of  the  visit  intended  to  be  paid  to 
him. 

In  addition  to  the  visitation  by  the  visiting 
justices,  "  every  licensed  house  not  within  the  imme- 
diate jurisdiction  of  the  Commissioners  in  Lunacy,  is 
to  be  visited  without  previous  notice  by  two  at  least 
of  the  Commissioners  (one  being  a  physician  or  sur- 
geon, the  other  a  barrister),  twice  at  least  in  every 
year." 

The  objects  of  all  such  visits  are  thus  stated  in  a 
report   issued  by  the    Commissioners   in    1847,    "to 


5b8      Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

ascertain  that  the  patient  is  duly  confined,  that  he  has 
medical  aid,  fit  attendance,  and  proper  comforts  during 
his  confinement,  that  he  is  provided  with  employment 
and  amusement ;  that  his  food  is  good,  and  his 
place  of  residence  healthy,  clean,  well  ventilated,  and 
in  good  order ;  that  he  himself  is  not  ill-treated,  neg- 
lected, or  improperly  restrained  ;  and  finally,  that  he 
is  liberated  when  fit  for  liberation."  And  thus  with 
regard  to  the  results  ;  "  without  adverting  to  the  many 
cases  where  persons  have  been  restored  to  the  world 
by  means  of  such  intervention,  important  benefits  and 
comforts  of  various  sorts  have  been  obtained  for  insane 
patients  by  the  present  system  of  inspection  and 
supervision.  The  dwellings  for  the  insane  are  no 
longer  the  gloomy  prisons  in  which  they  were  formerly 
confined  j  cleanliness,  warmth,  and  ventilation  are  in- 
sisted upon;  better  diet,  clothing,  and  bedding  have 
been  provided  ;  personal  restraint  is  diminished,  and 
even  when  still  employed,  its  severity  is  greatly  miti- 
gated, and  its  application  strictly  watched  ;  the  health 
and  mental  condition  of  the  lunatic  are  more  carefully 
considered  ;  occupation  and  amusement  are  more  gene- 
rally afforded  to  him,  and  in  all  respects  better  treatment 
is  secured,  whilst  an  opportunity  is  periodically  given 
to  him  of  representing  any  hardship  to  which  he  may 
have  been  subjected,  an  advantage  which,  as  is  found 
by  experience,  many  patients  fully  appreciate."  All 
this  is  undoubtedly  true,  and  I  look  upon  many  of 
these  advantages  as  the  gratifying  result  of  an  in- 
creased knowledge  of  mental  disease,  by  means  of 
which  the  mind  of  the  lunatic  has  been  carefully  ex- 
plored, and  everything  turned  to  account  which  is  not 
drawn  within  the  noxious  influence  of  local  perver- 
sion. I  use  the  word  local  advisedly,  being  of  opinion 
that  there  are  comparatively  few  cases  of  lunacy  in 
which,  during  a  considerable  period  of  the  attack,  the 
mind  does  not  retain,  with  judicious  treatment,  many 


Chap.  XXIV.]  Pauper  Lunatics.  .509 

influences  applicable  to  the  ordinary  phenomena  of 
normal  life. 

Provision  is  also  made  that  letters  addressed  by 
lunatics  to  the  Commissioners  should  be  forwarded 
unopened,  and  that  facility  should  be  allowed  them 
for  being  visited  by  their  friends ;  friends  are  also 
enabled  to  obtain  particulars  concerning  those  con- 
fined, or  supposed  to  have  been  confined  as  lunatics, 
upon  application  to  the  Commissioners.  Letters,  if 
not  sent  as  addressed,  must  be  kept,  after  being 
initialed,  for  the  authorities  to  see. 

Of  the  books  directed  to  be  kept  in  asylums,  the 
most  important  is  the  medical  case  book.  In  this  a 
statement  is  to  be  entered,  immediately  upon  entrance, 
of  the  name,  age,  sex,  and  previous  occupation  of  the 
patient,  whether  married  or  single,  his  or  her  external 
appearance,  habit  of  body,  temperament,  appearance 
of  eyes,  expression  of  countenance,  previous  habits^ 
any  peculiarity  in  the  fornj  of  the  head,  and  a  large 
number  of  medical  particulars  with  regard  to  physical 
condition,  a  description  of  the  phenomena  of  the 
mental  disorder,  changes  in  temperament  or  disposi- 
tion, etc.  etc.  During  the  first  month  after  admission, 
entries  in  this  book  must  be  made  at  least  once  in 
every  week,  oftener  where  the  nature  of  the  case  re- 
quires it ;  after  this,  once  a  month,  and  in  chronic 
cases,  once  in  three  months.  A  record  of  the  treat- 
ment adopted  is  also  to  be  subjoined. 

I  now  come  to  the  subject  of  pauper  lunatics, 
who  form  by  far  the  most  numerous  class ;  though 
the  regulations  concerning  them  and  the  institu- 
tions in  which  they  are  confined  can  be  embodied 
in  more  succinct  form  than  the  foregoing.  I  cannot 
do  better  than  quote  the  following  passage,  which 
will  give  a  clear  idea  as  to  their  position  in  the 
country.  Pauper  lunatics,  whether  they  are  paupers 
in  respect  of  destitution  existing  independent  of  their 


5IO      Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

lunacy,  or  in  consequence  of  it,  "  must  be  relieved 
by  the  guardians,  or  other  local  authorities  who 
are  charged  with  the  administration  of  relief  to  the 
poor ;  but  the  relief,  on  the  other  hand,  must  be 
afforded  in  the  particular  manner  which  is  pointed  out 
or  prescribed  by  the  law  as  adapted  to  the  peculiar 
circumstances  of  their  unfortunate  condition.  When- 
ever it  is  requisite  or  proper  to  do  so  for  the  purpose 
of  care  or  treatment,  they  ought  to  be  sent  to  the 
county  or  borough  asylum,  or,  in  default  of  such  ac- 
commodation, to  some  registered  hospital  or  licensed 
house  j  but  where  it  is  not  necessary  to  adopt  that 
course,  they  may  either  be  kept  in  the  workhouse  or 
be  lodged  with  relatives  or  friends,  or  be  boarded  out, 
or  otherwise  maintained  as  may  be  deemed  most  suit- 
able ....  thus,  in  respect  of  their  lunacy, 
pauper  lunatics  come  under  the  jurisdiction  of  the 
Commissioners  in  Lunacy,  whilst  in  respect  of  their 
pauperism  they  come  under  the  jurisdiction  of  the 
Local  Government  Board." 

The  county  and  borough  asylums  in  which  the 
numerous  class  of  pauper  lunatics  are  for  the  most 
part  confined,  are  comparatively  a  recent  creation. 
Anterior  to  1808,  the  only  enactments  affecting 
pauper  lunatics  were  the  provisions  of  vagrant  acts, 
"  authorising  the  detention  of  dangerous  maniacs  in 
chains  if  necessary,  rather  with  a  view  to  the  pro- 
tection of  the  public  than  for  their  own  benefit." 
Then  successive  legislation  left  it  to  the  option 
of  the  justices  as  to  whether  they  should  provide 
asylums  or  not,  and  it  was  not  till  1845  that  stipu- 
lation was  made,  "  rendering  it  incumbent  upon  the 
justices  of  every  county  or  borough,  not  already 
provided  with  an  asylum,  to  obtain  one  either  sepa- 
rately or  jointly  with  other  counties  or  boroughs." 
From  the  seventh  annual  report  of  the  Commissioners 
in  Lunacy  issued  in  1853,  it  appeared  "that  in  1852 


Chap.  XXIV.]  County  and  Borough  Asylums.     511 

there  were  still  several  counties  unprovided  with 
asylums,  and  that  there  were  only  four  boroughs 
which  separately  possessed  one."  At  the  present 
time,  however,  the  expenditure  of  these  institutions  is 
defrayed  out  of  the  county  rates  to  be  raised  for  the 
purpose  in  the  case  of  counties  ;  and  in  the  case  of 
boroughs,  either  out  of  the  borough  rates  or  out  of  the 
borough  funds,  as  the  council  of  each  borough  may 
determine.  Two  or  more  asylums  may  be  provided 
for  any  county  or  borough  where  necessary,  and  a 
separate  committee  of  visitors  appointed  for  each 
asylum.  The  asylums  are  ostensibly  provided  by 
each  county  or  borough  "  for  the  pauper  lunatics 
thereof,"  the  word  lunatic  bearing  the  old  interpreta- 
tion of  "  every  person  of  unsound  mind,  and  every 
person  being  an  idiot."  The  justices  have  the  power 
to  appoint  committees  of  visitors  to  manage  the 
asylums  thus  provided.  "  Such  visitors  may  enter 
into  temporary  contracts  for  sending  pauper  lunatics 
into  the  asylums  of  other  counties  or  boroughs,  or  into 
registered  hospitals  or  licensed  houses,  as  well  as  for 
receiving  pauper  and  other  lunatics  of  other  counties 
or  boroughs  into  their  own  asylums,  when  there  is 
accommodation  to  spare."  I  may  say  here,  however, 
that  the  flux  generally  lies  the  other  way :  large 
numbers  of  patients  who  have  passed  a  considerable 
time  in  licensed  houses  and  hospitals,  having  to  be 
discharged  when  their  slender  resources  are  ex- 
hausted, or  in  accordance  with  the  regulations  of 
such  institutions,  to  make  way  for  those  cases  in 
which  there  is  greater  prospect  of  cure.  These  and 
similar  cases  find  their  way  at  last  into  county 
asylums.  Yet  in  many  other  cases,  especially 
those  in  which  any  undue  social  exaltation  or 
pride,  or  vanity,  bear  a  part  in  the  symptoms  (and 
such  cases  are  by  no  means  few  in  number),  there  are 
doubtless  many  who  reap  a  benefit  from  the  change  of 


512      Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

surroundings,  and  recover,  tlieir  recovery  being,  no 
doubt,  partly  due  to  the  wholesome  change. 

With  regard  to  the  management  of  such  institu- 
tions, "  the  committee  of  visitors  are  to  make  general 
rules  for  the  government  of  the  asylum,  with  the 
approval  of  the  Secretary  of  State  \  and  subject  to 
such  general  rules  they  may  from  time  to  time  make 
orders  and  regulations  for  the  management  and  con- 
duct of  the  asylum,  setting  forth  the  number  and 
description  of  officers  and  servants  to  be  kept,  their 
duties  and  salaries ;  the  diet  of  the  patients ;  the  re- 
servation of  beds  for  certain  cases  ;  and  the  exclusion 
of  persons  afflicted  with  any  contagious  or  infectious 
disease,  or  coming  from  a  district  where  any  such 
disease  prevails."  There  must  be  a  chaplain  in  priest's 
orders  licensed  by  the  bishop  of  the  diocese,  a  resident 
medical  officer  who  is  in  the  majority  of  cases  the 
superintendent  of  the  asylum,  together  with  a  clerk 
and  treasurer,  and  many  other  officers.  Provision  is 
made  for  patients  belonging  to  a  religious  persuasion 
differing  from  that  of  the  Established  Church,  who 
may  be  visited  by  ministers  of  their  own  denomina- 
tion. Strict  regulations  are  made  about  the  accounts, 
which  have  to  be  submitted  to  the  committee  of 
visitors,  the  Secretary  of  State,  and  the  Lunacy  Com- 
missioners. Annual  lists  of  all  pauper  lunatics  through- 
out the  country  have  to  be  made  out  at  the  beginning 
of  each  year,  which  lists,  prepared  by  the  clerks  to  the 
guardians  or  overseers  of  parishes,  must  be  forwarded 
to  the  committee  of  visitors,  to  the  justices  of  coun- 
ties and  boroughs,  to  the  Commissioners  in  Lunacy,  and 
the  Local  Government  Board.  These  asylums  are 
visited  by  the  Commissioners  in  Lunacy  once  in  every 
year,  thus  it  will  be  seen  that  the  most  elaborate  scrutiny 
is  exercised  over  the  details  of  their  management. 

With  regard  to  the  imode  of  adTnission  to  such 
institutions,  we  have  already  Feen  that  the  object  of 


Chap.  XXIV.]  County  AND  Borough  Asylums.      513 

the  statutes  is  to  secure  the  reception  into  such 
asylums  of  all  those,  and  those  only,  who  are  fit  sub- 
jects for  its  treatment.  "  On  becoming  aware  that 
any  pauper  resident  in  his  district  is,  or  is  deemed  to 
be,  a  lunatic,  and  a  proper  person  to  be  sent  to  an 
asylum,  the  medical  officer  is  to  give  written  notice 
thereof  within  three  days  to  the  relieving  officer ;  or 
if  there  be  no  relieving  officer,  to  the  overseers." 
Again,  ''  on  becoming  aware  that  any  pauper  resident 
in  his  parish  is,  or  is  deemed  to  be,  a  lunatic,  the  re- 
lieving officer  (irrespective  of  the  question  of  his 
insanity)  is  required  to  give  notice  to  some  justice  of 
the  county  or  borough,  who  is  thereupon  to  deal  with 
the  case,  unless  the  pauper  cannot  be  conveniently 
taken  before  a  justice,  in  which  case  he  may  be 
examinedj  and  the  requisite  order  made  by  an  offi- 
ciating clergyman  of  the  parish,  in  conjunction  with 
the  relieving  officer."  Where  there  are  no  relieving 
officers,  these  duties  are  discharged  by  the  overseers. 
The  justice,  upon  examination  of  the  alleged  pauper 
lunatic,  or  the  certificate  concerning  him,  or  being 
satisfied  that  he  is  "  a  proper  person  to  be  taken  charge 
of  and  detained  under  care  and  treatment,"  may 
make  an  order  for  his  reception ;  and  if  certificates 
are  given  jointly,  by  both  the  medical  officer 
called  in  by  the  justice,  and  the  medical  officer 
of  the  parish  or  union,  he  is  bound  by  the  statute 
without  alternative  to  make  such  an  order,  accom- 
panied with  certain  particulars,  and  "directing"  the 
superintendent  of  the  asylum  to  receive  the  pauper  as 
a  patient.  The  regulations  in  all  matters  concerning 
the  certificates  are  as  stringent  and  almost  identical 
with  those  to  which  I  have  referred  in  the  case  of 
private  lunatics. 

There  are  some  other  important  regulations  of  the 
Commissioners,  applying  for  the  most  part  equally  to 
licensed  houses,  to  registered  hospitals,  and  to  county 
H  H — 14 


514     Insanity  AND  Allied  Neuroses.  [Chap.  xxiv. 

asylums,  which  I  have  reserved  to  consider  in  this 
place.  In  the  matter  of  a  patient  suffering  ill-treatment 
at  the  hands  of  any  superintendent,  officer,  nurse, 
attendant,  servant,  or  other  person,  whether  this  be 
owing  to  violence  or  neglect,  such  person  is  liable  to 
be  fined  ,£20,  or  be  indicted  for  misdemeanour.  Into 
this  subject  we  have  already  entered  to  a  certain 
extent  when  speaking  of  lunatics  under  the  imme- 
diate charge  of  their  friends.  Suffice  it  to  say  here, 
that  the  regulations  of  the  Commissioners  are  espe- 
cially directed  towards  a  prevention  of  the  above. 
One  of  their  regulations  is  to  the  effect  that  the  dis- 
missal of  any  nurse  or  attendant  for  misconduct  is 
to  be  reported,  together  with  the  cause  of  it,  within 
one  week.  The  object  of  this,  they  say,  "is  by 
means  of  a  central  register  available  for  general  refer- 
ence, to  prevent  improper  persons  from  being  em- 
ployed in  the  care  of  the  insane." 

If  any  lunatic  escape  from  the  asylum  or  hospital  in 
which  he  is  confined,  notice  is  to  be  given  to  the  Com- 
missioners within  three  days,  and  if  the  house  be 
licensed  by  justices,  to  the  visitors  also.  If  retaken 
within  fourteen  days  he  may  be  retained  under  the 
original  order  and  certificates,  but  not  otherwise.  If 
the  escape  occur  through  the  connivance  of  any  officer 
or  servant,  he  will  be  liable  to  a  penalty  of  £20. 
Notice  must  also  be  given  of  the  recapture. 

On  the  recovery  of  any  lunatic,  if  he  be  confined 
in  a  licensed  house  or  registered  hospital,  "  notice 
must  be  given  to  the  person  who  signed  the  order  of 
admission,  or  by  whom  the  last  payment  was  made  ; 
and  if  the  patient  be  not  removed  within  fourteen  days, 
notice  must  then  be  given  to  the  Commissioners,  and 
hi  the  case  of  a  house  licensed  by  justices,  to  the  visi- 
tors also.  Any  person  may  be  discharged  or  removed, 
whether  recovered  or  not,  by  the  order  in  writing  of 
the  person  who  signed  the  order  of  admission ;  .   .    .   . 


Chap.  XXIV.]  County  AND  Borough  Asylums.      515 

but  if  the  lunatic  be  dangerous,  the  consent  of  the 
Commissioners  or  visitors  must  be  obtained  for  his 
discharge  or  removal,  though  he  may  be  transferred  to 
some  other  establishment,  under  the  control  of  an 
attendant."  In  the  case  of  a  pauper  lunatic  having 
recovered  in  a  county  asylum,  the  power  to  discharge 
him  rests  with  the  visitors  of  the  asylum,  any  three  of 
whom,  or  any  two  with  the  advice  of  the  medical 
officer,  may  direct  such  discharge.  The  visitors  may 
notify  their  intention  to  the  overseers  of  the  parish  in 
which  the  pauper  is  settled,  or  from  which  he  was 
sent,  or  to  the  relieving  officer,  in  which  case  they 
must  see  to  his  removal  forthwith.  Provision  is  also 
made  for  delivering  any  pauper  lunatic  to  his  rela- 
tives or  friends,  on  their  giving  an  undertaking  to  the 
satisfaction  of  the  visitors,  "that  he  shall  be  no 
longer  chargeable  to  any  union,  parish,  or  county,  and 
shall  be  prevented  from  doing  injury  to  himself  and 
others."  There  is  also  a  charitable  fund  established  to 
meet  the  wants  of  such  persons  after  they  have  been 
discharged,  and  until  they  are  able  to  resume  their 
ordinary  labour.  {See  Thirteenth  Report  of  the  Com- 
missioners, 1859.) 

If  it  be  thought  that  tem-porary  absence  from  an 
asylum  would  be  desirable  in  reference  to  any  patient, 
this  is  provided  for  by  the  statutes  in  the  case  of 
private  patients  by  allowing  them  to  "  go  to  a  speci- 
fied place  for  a  definite  length  of  time,  or  to  be  out  on 
trial  for  a  specified  period."  In  the  case  of  pauper 
lunatics,  "  any  two  of  the  visitors,  with  the  advice  in 
writing  of  the  medical  officer  of  the  asylum,  may  per- 
mit any  patient  to  be  absent  from  the  asylum  on  trial, 
for  such  period  as  he  may  think  fit,  making  an  allow- 
ance to  him,  the  amount  whereof  is  to  be  charged  and 
paid  as  if  he  were  in  the  asylum."  But  it  must  be 
remembered,  that  "  if  any  superintendent,  officer,  or 
servant  permit  any  patient  to  be  at  large,  save  in  the 


5i6      Insanity  and  Allied  Neuroses.  [Chap.  xxiv. 

case  of  temporary  absence  cliilj  authorised,"  lie  will 
liable  to  a  penalty. 

Provision  is  also  made  for  the  transfer  of  patients 
from  one  asylum  or  hospital  to  another  ;  the  proposal 
must  originate  with  those  having  authority  to  order 
the  discharge  of  the  patient,  and  the  consent  of  two  of 
the  Commissioners  must  be  obtained  ;  "  fresh  medical 
certijficates  need  not  be  obtained,  but  copies  of  the 
original  order  and  certificates,  together  with  the  order 
of  removal  and  consent,  must  be  given  to  the  pro- 
prietor or  superintendent  of  the  house  or  hospital  to 
which  the  patient  is  transferred."  Where  people  have 
to  undertake  the  transfer  of  private  patients,  if  de- 
sired, persons  may  be  generally  found  who  are  willing 
to  contract  for  the  expense  incurred,  and  undertake 
the  responsibility.  In  the  case  of  pauper  lunatics,  the 
visitors,  being  justices,  "  subject  in  certain  cases  to  the 
consent  in  writing  of  two  of  the  Commissioners,  may 
address  an  order  to  any  overseer,  relieving  officer,  or 
other  person  to  effect  the  transfer." 

Whenever  the  death  of  a  patient  occurs,  in  whatever 
class  of  asylum,  a  certificate  must  be  drawn  up  by  the 
medical  officer,  stating  the  cause  of  death,  and  men- 
tioning the  name  of  any  attendant  or  relative  present. 
A  copy  of  this  must  be  sent  to  the  Commissioners,  to 
the  person  who  signed  the  order  for  admission,  to  the 
registrar  of  deaths,  and  to  the  coroner ;  and  where 
the  house  is  licensed  by  justices,  to  the  clerk  of  the 
visitors.  Suitable  entries  must  also  be  made  in  the 
books  of  the  establishment,  and  particulars  sent  to  the 
coroner  so  that  he  may  hold  an  inquest  if  necessary. 
The  expenses  of  the  burial  of  pauper  patients  are 
borne  by  the  union,  parish,  or  county  to  which  the  de- 
ceased was  chargeable. 

With  regard  to  the  subject  of  pauper  lunatics  in 
workhouses^  we  have  already  seen  that  it  is  intended 
that  all  such  cases  as  are  in  any  way  suitable  should 


Chap.  XXIV.]   County  and  Borough  Asylums.      517 

be  sent  to  the  county  asylum ;  and  it  is  prohibited  to 
restrain  any  "  dangerous  lunatic,  dangerous  insane 
person,  or  dangerous  idiot,"  in  a  workhouse  for  more 
than  fourteen  days,  nor  may  he  be  retained  when  he 
has  been  reported  as  such  by  the  medical  officer,  or 
when  he  requires  "frequent  or  habitual  restraint." 
The  preceding  prohibition  applies  more  especially 
to  the  case  of  dangerous  lunatics,  but  it  does  not 
of  course  follow  that  all  lunatics  who  are  not 
dangerous  may  be  so  retained.  Nevertheless,  it 
certainly  appears  that  where  certain  individuals  are 
not  deemed  suitable  to  be  sent  to  an  asylum,  as,  for 
example,  in  the  case  of  harmless  idiots  and  others, 
these  persons  may  be  legally  detained  in  a  workhouse 
even  against  their  will ;  and  in  some  workhouses,  as  is 
known,  there  are  even  separate  wards  set  apart  for  the 
insane  paupers.  "  The  existence  of  such  wards  is  not 
unlawful,  but  it  will  be  a  question  in  every  case  how 
far  the  lunatics  maintained  in  them  may  be  proper 
persons  to  be  sent  to  an  asylum."  Special  legislation 
upon  this  subject,  I  may  say,  exists  in  the  metropolis, 
into  which,  however,  we  cannot  enter  here.  Pauper 
lunatics  who  are  not  fit  subjects  to  be  sent  to  an 
asylum,  may  also  receive  out-door  relief,  when  in 
charge  of  relatives  or  otherwise  :  they  must  be  visited 
quarterly  by  the  medical  officer. 

In  the  case  of  private  lunatics  in  county  or 
borough  asylums,  it  is  provided  that  where  the 
accommodation  admits  of  it,  the  committee  of  visitors 
may  take  means  to  admit  upon  payment  a  certain 
number  of  lunatics,  not  paupers,  who  may  be 
"  proper  subjects  to  be  admitted  into  a  public 
asylum."  They  may  require  "  that  no  lunatic 
shall  be  admitted  without  an  undertaking  by  the 
person  signing  the  order  for  admission  for  the 
due  payment  of  the  weekly  charge  for  the  lodging, 
maintenance,    medicine,    clothing,    and  care    of    such 


5i8      Insanity  AND  Allied  Neuroses.  [Chap.  xxiv. 

lunatic  during  his  continuance  in  the  asylum,  and  of 
the  expenses  of  his  burial  in  case  he  die  therein,  as 
well  as  for  his  removal  from  the  asylum  within  six 
days  after  due  notice  given  in  writing  by  the  super- 
intendent of  the  asylum."  Such  lunatics  "  are  to 
have  the  same  accommodation  in  all  respects  as  the 
paupers."  There  are  provisions,  however,  in  the 
statutes  relating  to  lunatics  so  circumstanced,  which 
tend  to  include  them  under  similar  regulations,  and 
to  afford  them  similar  privileges,  when  possible,  to 
those  of  private  lunatics  in  registered  hospitals  and 
licensed  houses. 

Wandering  lunatics  or  lunatics  found  improperly 
provided  for,  are  not  included  in  any  of  the  foregoing 
classes,  yet  there  are  certain  provisions  in  respect  to 
them  which  must  be  duly  observed.  If  such  a  lunatic 
be  found  by  any  person  he  should  give  notice  to  a 
constable,  overseer,  or  relieving  officer,  and  such 
officer  is  bound  to  cause  him  to  be  taken  before  a 
justice,  who^  when  it  is  made  known  to  him  (the 
justice)  "upon  oath  of  any  person  whomsoever,"  that 
any  such  person  exists  within  the  limits  of  his  juris- 
diction, must  order  him  to  be  brought  before  him. 
After  calling  to  his  aid  a  medical  man,  they  may 
make  an  order  for  his  reception  into  any  registered 
hospital,  asylum,  or  licensed  house.  The  justice  may 
act  upon  his  own  knowledge  in  such  a  matter,  he  may 
suspend  the  execution  of  his  order  for  fourteen  days 
if  necessary  ;  the  medical  man  may  also  require  the 
order  to  be  suspended.  The  lunatic,  when  he  has 
been  sent  to  the  asylum,  becomes  a  pauper  "  as  re- 
gards his  maintenance  therein,"  and  is  dealt  with  as 
such,  until  he  is  taken  under  the  charge  of  his  friends 
and  relations.  The  lunatic,  however,  may  be  given 
up  to  his  friends  if  they  satisfy  the  justice  (or  the 
visitors  of  the  asylum.,  if  he  has  been  incarcerated 
therein),  that  proper  care  will  be  taken  of  him. 


Chap.  XXIV.]  Criminal  Lunatics.  519 

Criminal  lunatics. — Having  previously  referred 
to  the  question  of  the  legal  responsibility  of  the  insane, 
I  will  now  endeavour  briefly  to  summarise  the  provi- 
sions of  the  law  with  respect  to  criminal  lunatics, 
which  consists  of  («)  individuals  certified  to  be  insane 
whilst  awaiting  trial  for  an  offence  ;  (3)  those  acquitted 
or  reprieved  on  the  ground  of  insanity  ;  (7)  those  felons 
certified  to  have  become  insane  whilst  undergoing  sen- 
tences of  penal  servitude.  There  is  another  class, 
consisting  of  those  who  were  about  to  commit  a  crime, 
but  who  were  prevented  from  doing  so,  concerning 
whom  it  is  provided  "  that  any  person  so  apprehended 
may  be  sent  by  two  justices,  acting  with  the  advice  of 
a  medical  man,  to  the  county  asylum,  if  there  be  one; 
and  if  not,  to  some  hospital  or  licensed  house,  to  be 
there  maintained  at  the  charge  of  the  parish  of  his 
settlement,  and  if  such  parish  cannot  be  ascertained, 
at  the  charge  of  the  coanty  or  borough  where  he  was 
apprehended."  It  being  allowed,  however,  that  the 
property  of  criminal  lunatics  should  be  applied  towards 
their  maintenance,  I  should  presume  from  these  pro- 
visions that  most  lunatics  of  this  description  are  likely 
to  come  under  the  the  class  of  ''  wandering  lunatics  " 
referred  to  in  the  preceding  section,  who  may  be  pro- 
vided for  by  their  friends,  or  for  whom  the  conditions 
of  their  restraint  may  be  arranged  by  these  latter. 
Substantially  the  provisions  are  the  same,  and  if  found 
to  be  borne  out  by  experience,  I  cannot  see  that  the 
above  need  be  included  in  the  class  of  criminal  lunatics 
as  recognised  by  the  law,  although  I  notice  that  they 
have  been  referred  to  under  this  head  before. 

In  regard  to  this  subject,  Blackstone  points  out 
"  that  if  a  man,  who  in  his  sound  mind  has  com- 
mitted an  offence,  becomes  mad  before  arraignment, 
he  ought  not  to  be  arraigned  ;  if  after  he  has  pleaded, 
and  before  trial,  he  ought  not  to  be  tried ;  if  after 
trial  and  a  verdict  of  guilty,  but  before  judgment, 


520     Insanity  and  Allied  Neuroses,  ichap.  xxiv. 

judgment  ouglit  not  to  be  pronounced ;  and  if  after 
judgment,  execution  ought  to  be  stayed."  This  con- 
cise statement  of  the  obligations  imposed  upon  the 
law  was,  towards  the  beginning  of  the  present  century, 
met  with  the  following  provision,  which  in  the  main, 
T  believe,  holds  at  the  present  day ;  "  that  if  a  person 
charged  with  treason,  murder,  or  felony  (or  any  mis- 
demeanour), be  acquitted  on  the  ground  that  he  was 
insane  at  the  time  of  committing  the  offence,  the  jury 
shall  find  specially  to  that  effect ;  and  in  any  case, 
and  also  where  a  person  indicted  for  any  offence,  or 
brought  up  to  be  discharged  for  want  of  prosecution, 
is  found  to  be  insane  either  by  the  jury  charged  with 
the  indictment,  or  by  a  jury  impanelled  for  the  pur- 
pose, the  court  is  empowered  to  direct  his  confinement 
until  the  Queen  shall  give  order  for  his  safe  custody 
during-  her  pleasure,  in  such  place  and  in  such  manner 
as  to  her  Majesty  may  seem  fit." 

In  this,  however,  there  is  no  mention  of  any 
special  provision  having  been  made  for  the  accommo- 
dation of  insane  criminals,  and  many  persons  of  this 
description,  without  doubt,  were  still  kept  in  the 
county  gaols  and  houses  of  correction,  instead  of  being- 
placed  in  more  suitable  establishments.  But  in  1807 
a  select  committee  of  the  House  of  Commons  was  ap- 
pointed to  enquire  into  the  condition  of  the  criminal 
and  pauper  lunatics  throughout  England  and  Wales, 
and  in  their  report  they  strongly  recommended  the 
establishment  of  a  central  asylum.  It  was  not  till 
1816  that  arrangements  were  made,  at  the  charge 
of  the  government,  for  the  provision  of  accommoda- 
tion for  sixty  criminal  lunatics  in  connection  with 
Bethlem  Hospital,  who,  though  dependent  upon  the 
government  for  their  maintenance,  were  under  the 
care  of  the  governors  of  the  hospital  as  to  all  other 
matters.  We  gather  from  the  reports  of  the  Com- 
missioners   that,    in  time,    the    number    of    patients 


Chap.  XXIV.]  CrIMINA  L    L UNA  TICS.  5  2 1 

nearly  doubled,  and  ultimately,  in  1849,  "an 
agreement  was  entered  into  with  the  proprietor  of 
Fisherton  House,  near  Salisbury,  for  the  erection  of  a 
detached  ward  for  the  same  class."  It  was  evident 
that  matters  were  now  tending  towards  the  establish- 
ment of  a  separate  asylum  for  criminal  lunatics.  At 
length,  in  1863,  such  an  asylum  was  formally  opened 
at  Broadmoor,  near  Wokingham,  Berks,  an  establish- 
ment which  has  been  found,  I  believe,  to  answer  the 
purpose  for  which  it  was  designed.  This  state  asylum, 
which  includes  also  those  who  have  been  found  insane 
whilst  undergoing  sentences  of  penal  servitude,  or  of 
imprisonment,  are  visited  by  the  Commissioners  in 
Lunacy,  who  report  thereon  to  the  Secretary  of  State, 
with  whom,  I  may  say,  rests  the  power  of  directing 
the  removal,  temporary  absence,  or  discharge  of  any 
criminal  lunatic  confined  therein. 


APPENDIX. 


Forms  of  Ordek,  Statement  and  Certificate, — Errors  in 
Certificates.  —  Form  of  Affidavit.  —  Hospitals  for 
THE  Insane  and  Idiot  Asylums. — Private  Asylums. 


Lunatics  1. 
(16  &  17  Vict. 

C.  9 !.) 

private 
patient. 


N.B. —  Tinder  all  circumstances,  if  possible,  the  "  Order  ^^  and 
*^ Statement  ^^  below  to  be  filled  up  by  the  patienVs  relatives.  If 
no  relatives,  by  the  nearest  friend. 

"OEDEE"    FOE   THE    EECEPTIOI^   OF   A  PEIYATE 

PATIENT. 


(A)  Within 
one  month 
previiius  to 
the  date  of 
the  order. 

(B)  "  Luna- 
tip,"  or  "  an 
idiot,"  or  "  a 
person  of  un- 
sound mind." 
(CJ"  Order" 
must  be 
signi  d,if  pns- 
sible.hy  near- 
est relative. 


Sched.  (A)  No.  1,  Sects.  4,  8. 

jt^  the  -imdersigned,  hereby  request  you  to  receive  [name  of 

patient  in  full)  

■whom  I  last  saw  at 

on  the    (A) day  of 188 

a  (B) as  a  patient  in  your  Hospital. 

Subjoined   is  a  statement    respecting  the  said  {name   of 
patient  in  full) 

Name,  (C)  

Occupation  (if  any)   

Place  of  abode 

Degree  of  relationship  (if  any)  "^ 

or  other  circumstances  of  con-  > 

nection  with  the  patient         .)  

B.itttf    this day    of one  thousand 

eight  hundred  and 

To  the 

Superintendent  of 


Statement  of  Lunacy. 


523 


STATEMENT. 

If  ant  Pakticvlars  ix  this  Statemext  be  not  Known,  the 

Fact  to  be  so  Stated. 

iN'ame  of  patient,   with  Chj-istian  name  | 
at  length    ..... 

Sex  and  age   ..... 

Married,  single,  or  widowed  . 

Condition   of  life,    and  previous  occu 
pation  (if  any)     .... 

Eeligious  persuasion,  as  far  as  known 

Previous  place  of  abode. 

Whether  first  attack 

Age  (if  known)  on  first  attack 

WHEN  and  WHERE  previously  under  | 
care  and  treatment     .         .         .         .  / 

Duration  of  existing  attack   . 

Supposed  cause       .... 

Whether  subject  to  epilepsy  . 

Whether  suicidal    .... 

Whether  dangerous  to  others 

Whether  found  lunatic  by  inquisition, ") 
and  date  of  commission  or  order  for  > 
inquisition  .         .         .         .         .  j 

Special  circumstances  (if  any)  prevent- 
ing the  patient  being  examined,  be- 
fore admission,  separately  by  two 
medical  practitioners  .... 

Name  and  addi'ess  of  relative  to  whom 
notice  of  death  to  be  sent   . 


Name,  (E)  

Occupation  (if  any) 

Place  of  abode 

Degree  of  relationship  (if  any), 
or  other  circumstances  of  con- 
nection with  the  patient  . 

8  &  9  YICT.,  Cap.  100,  Sec.  XLV. 


Dates  must 
te  inserted. 


N.B. — Medical  certificates  of  patient's  examination,  and  the 
signatures,  are  required  by  the  above  statute  to  be  dated 
within  seven  clear  days  of  the  patient's  reception.  In 
stating  the  residence  the  number  of  the  house  must  be 
specified,  when  there  is  any,  and  if  not,  the  name  of  the 
occupier. 


(E)  The 
"Statement" 
must  be 
signed,  but 
"  whei-e  the 
PC'sun  sign- 
ing the  state- 
ment is  not 
the  person 
who  signs  r he 
order,  the  fol- 
lowing parti- 
culars con- 
cerning the 
person  sign- 
ing the  state- 
ment are  to 
be  added." 


524      Insanity  AND  Allied  Neuroses. 

The  medical  men  signing  the  certificates  must  not  he  in 
partnership,  nor  one  an  assistant  of  the  other ;  and  they 
must  use  the  terms  specified  in  the  statute,  for  which  see 
the  notes  of  reference  helow. 


By  Order  of  the  Commissioners  in  Lunacy. 

1. — It  is  ahsolutely  necessary  that  the  medical  men  should 
write  their  certificates  legihly,  so  as  to  afford  the  oppor- 
tunity of  an  exact  copy  heing  made. 

2. — "  All  alterations  in  the  original  certificates,  unless  hy  the 
certifying  medical  men,  invalidate  them ;  and  the  initials  of 
the  latter  must  he  placed  to  every  change  or  addition 
made." 

3. — "  If  a  registered  medical  man  descrihes  himself  as  *  a  duly 
qualified  registered  practitioner,'  it  is  not  necessary  that 
he  should  specify  his  medical  qualifications  in  full,  in 
addition." 


The  following  exhibits  the  relative  frequency  of  mistakes  in 
certificates  per  cent.  : 

The  most  common  mistake  is  the  omission  of  the  name  of 
the  person  who  has  communicated  the  facts ;  the  next  most 
common  is  the  omission  of  the  occupation  of  the  patient,  and 
next  the  omission  of  the  address  in  full.  Notwithstanding  the 
directions  given  in  the  margin,  many  certificates  are  written 
with  *' general  practitioner"  in  place  of  physician,  surgeon,  or 
apothecary. 

In  nine  per  cent,  alterations  had  to  he  made  in  the  facta 
observed  hy  the  medical  man,  things  heing  placed  under  this 
head  which  could  not  have  been  observed,  or  else  unimpor- 

(A)  Here  set   tant  facts  recorded  which  might  have  depended  on  passion  or 

Sfl^adon  ^i^kj  and  not  on  insanity. 


entitling  .he  

person  certi- 

tfielsa^phy-'  MEDICAL  CEETIFICATE.— Sched.  (A)  No.  2 

sician,  sur- 

geon  orapo-  Sects.  4,  5,  8,  10,  11,  12,  13. 

thecary,  ex.  j     j     »        >        7        j 

quaii'fled re-    ^^  the  undersigned 

practitioner"  being  a  (A)  duly  qualified  registei-ed  practitioner [1]. 


sufficient.      ^"^^  being  in  actual  practice  as  a  (B) [15]- 

(B)"Physi-    hereby  certify  that  I,  on  the day  of 18 

SGon*'ot^^'  at  (C)  Here  insert  the  street  and  NUMBER  of  house  {if  any). 


Medical  Certificate.  525 

OR  NAME  IN  FULL  OF  OCCUPANT "apothe- 

(C) [21] in  the  county  of "^l/^i.'^l 

separately   from   any   other   medical    practitioner    personally  "  General 

examined. of  (D)  State  full  address  and^fy^^^x^^ 

OCCUPATION  {if  amj),  (D) [22] and  that  (^C). Here  in- 

the  said is  a   (E) [6] street,  and 

and  a  proper  person  to  be  taken  charge  of  and  detained  under  "heh'ouse^if 
care  and  treatment,  and  that  I  have  formed  this  opinion  upon  any),  or  other 
the  following  grounds,  viz. :  lars.^N.B.-if 

DO  street  nor 

1.  Facts  indicating  insanity  observed  hy  myself.   (F)  Some  hous-,  state 
<fe/mfe  FACT  or  FACTS  must  he  specified ofocrapint 

(D)A'.B.of 

TQ-i  insert  full 

L*'J  address  and 

occupation 

2.  Other  facts  (if  any)  indicating  insanity  communicated  (if  any). 

to  me  by   others    (G)    (State  the   NAME   IN   FULL  of  the  tf,'''o^T" 

person  giving  the   information) •■  ^*^^°*'"  S^of 

unsound 
rrt/?n  mind." 
L*aOj CF)  Here  in- 
sert the  facts. 
a;<vn.>vv  Some  definite 
Slgncn,                                                                                                                                 fact  or  facts 
-vr„™»                                                                                                                    mustbespe 

•^^^™6  cifled 

Place  of  abode pieaseto 

write  the 
facts  legibly, 

BatCtf    this day    of one    thousand  ^'^^g"ff*p^o®  si. 

eight  hundred  and ^le 

°  C4)  Here  state 

the  inforraa- 

tionandiaame 

—  in  full  from 

whom  re- 
ceived. 

FORM  OF  AFFIDAVIT  IN  CASES   OF  INQUISITION. 

This  should  he  a  concise  statement  of  all  you  know  of  the  case 
indicating  insanity,  put  in  distinct  paragraphs. 

1.  I,  A.  B.  (here  state  (1)  medical  qualification ;   (2)  special 
qualifications  for  understanding  insanity) 

2.  Having  had  the  following  opportunities  for  observing 
X.  Y.,  am  of  opinion  that  he  is  of  unsound  mind. 

3.  For months  his  conduct  has  been 

4.  His  memory  has  been  defective. 

5.  He  has  the  following  delusions 

6.  In  my  opinion  he  is  unfit  to  manage  himself  and  his 
affairs. 

7.  And  is  not  likely  to  recover  for  a  considerable  time,  if 
at  all. 


526        Insanity  AND  Allied  Neuroses. 


Ordtnary  Form  for   Case  Taking. 


Date  of  admission  

Name  Age 

Condition Occupation 

Heredity.  (1)  Nervous (2)  General... 

Supposed  causes    

Habits  of  life 

No.  of  attack Duration 

Earliest  symptoms  and  mode  of  development 

State  of  digestive  functions 

Appetite 

Bowels 

Eelated  delusions , 

State  of  reproductive  organs 

Sense  organs.     Eyes Ears 

Senses,  sigM 

„      hearing 

,,      taste  and  smell 

„      common  seuvsibility  

Delusions 

„        melancholic 

„        of  exaltation 

Suicidal  tendency Homicidal  tendency . 

Memory  of  (1)  recent ..(2)  distant  events. 

Reaction  to  questions 

Sleep Dreams 

Muscular  condition 

„        walk •.... 

„         reflexes    

Body  weiglit 

Condition  of  other  viscera 

Hand- writing 


Hospitals  FOR  the  Insane,  etc.        527 


a 

. 

3 

(B 

C 

d 

g 

^ 

^^ 


o  3 


CO 

< 
H 
I— I 
Ph 

C 


•-  h^ 


E,  "^ 

to  ^ 

to  ft 

CO  c3 


o 


<^      Ph 


3    s 


3 


Ph 


to  +2 


O  ^    oi 


•^  s 


CO  . 


cq  >^ 


01 


^       ^^ 


^  o 

c3 


JI>  '^  -u 


g  «       o 
43+5       O 

d  >J         ft 


-go    §^ 

C3   (p 


ftc3 


fl  o 


d        aj 


<A       ^ 
7       o 

00      'O 


^       b 


fl   ^ 


0 

•ft 

^ 

CO 

0   . 

ft 

■d 

w 

0 

:tt 

M 

ft 

»} 

0 

ff>  5R 

0) 

w 

^^ 

3 

^J 

1^ 

■  P 

rjQ      PP 


ft 
ft 
o 
O 


tJ     K!     rt 

o  +=  3 

05   Ol      « 
-tJ    >   0) 

5    V    0} 
(D  +3 


IB 


U    O 


d-^    ^ 

-go 

JJ  ft<B 
^      2 

f-i  [n  a 
O  «  M 


a;  5,^ 

II 


Ph 


o 


fl     O 


^      « 


d 

.3 
o 


528       Insanity  AND  Allied  Neuroses. 


'^ 


m 

< 

H 

M 
CO 

o 


M 


tti  t!  iJ 

0) 

-«  ^-^^ 

,ct 

y-S     ^      Q) 

CM 
0 

-^^53 

fl 

S  f=!  ft 

0 

S    fl    0! 

-P 

S^  03 

0) 

HJ-C    d 

;h 

(B  0)  pj 

0 

ft-?3  S 

-d 

co<j  o 


's^oa 

01 

-5  tn  ^ 

I-H 

CQ 

p  S  fl 

■P 

fl 

r^^r^    0 

aJ    =^r-j 

■^ 

the 

for 

ceive 

ft 

©3  ^ 

^n> 

•r„«> 

rj    a) 

03    6c  ^j 

B^ 

0;=)  c8 

■-:3  «  m 
c3  „ += 

^g 

§  2  S 

c  0 

— 1       JJ 

tJ  a^  5 

2-^  ir 

o\Z,  0 

0)    - 

11   p 
cur 
ma] 

So 

^w 

< 

Ph 

O  ro  -p  aj 

«t-  o3        ft 

<0   ^    ~ 

OJ  3  S  2:J 

d  _   o3  3 

O'-'  (DO 

beg  g'-'  he 
.5  ^-u  » .S 

ft         ^,2 

"  _2  fl  03  o 


S  c3 


H 


0 

w 

0 

-p 

« 

M 

■ft 

03 
0 

^ 

a 

■^ 
s 

1 

w 

f3 

fl     • 

-^ 

fM 

w 

^3 

^ 

u 

0 

^ 

M 

h 

H 

< 

<4 


o3 
O 


O 


W 


Metropolitan  Licensed  Houses. 


529 


g^ 


o  fl 


9< 


J5  J?  ■« 


U     5h 


_;  .;i  in      .  -2  =s  •= 


fi^N 


.    •     .  ro  a) 


o 


p    0)    o 

^.b  o  o  a 


■¥  o  ^H 


ii  * 


I  I— u 


544 

't§^  ■ 

« f^  rt  a 

•r  O  fi  9 

OS  P4  9:1  r^ 


3 


6  2 


c?  «"£  -'^  ios 
'c  .i  -p  fe  js  $  4i  3 


S  PI 

5i5  l5  i5-3'^"55'oo 


W      WW  M  WWWMHiHiJziP-i 


53° 


Insanity  and  Allied  Neuroses. 


"^g 


m 

XJl 

p 

O 

p 

CO 

o 


|2i 

<^ 

Eh 
I— I 
)J 
O 
Ph 
O 
P^ 
H 


d 

o 

-4J 

c3 

<o 

M 

d 

9 

03 
0! 

O 

rr-i 

01 
bo 

g 

Jd 

3 

.2 

Hi 

S 
o 

02 

4d  ••> 

11 

m  B 

« 

s 

'i 

S^.i^'S 

.  o 
P)  o 

O   0=  -g  '^  '-'  i_J 

E^ 

^> 

•^  fi    0)  HH  ^K  ^ 

S      .    S    ,•      .      .      .05 

> 

o 

Fh 

o 

a 

-^  . 

.  §  .  .  . 

a 

0)                   1-1 

fH            r;3 

DO 

h3 

.^  .  .  .w 

CO 

pi 

co' 

'^            -p 

(M 

O                 ro 
O                  c3 

O 

M 

S     . 

s 

h  O        5        m 

O 

33    . 

Siiverton 
e  Priory 
The  Shru 
le  (Jottage 
lliford  Ho 
ickenham 
vy  Lodge 
he  Hugue 

■^.^ 

CrH 

PhM 


CO 

p 

O 
W 

P 
[^ 

CO 

!zi 
o 


< 

I— I 

o 

I— I 

t> 

o 
p^ 

P4 


TJ 

a 

01 

oj 

ID 

•^3 

o 

1 
O 

1 

o 

,£5 

^ 

W 

^ 

^      ^  s 

O 

OQ 
03 

1 

:son. 
J.  Al 

wood. 
t  and 
I. 
kin,  s 

■^ 

•1 

'5 

5 

Phillips, 
K.  Dick 
and  Mr. 
1.  A.  Tea 
.  Locke. 
W.  East 
.  Garbut 
.  Millarr 
M.  Tom 

o 

^fed^^hJ^^^H 

^ 

0 

5^  C  ^.2  C  ^  C  t^  u 

fi 

'-^ v~ 

'g^fig^qgg^ 

• 

o3 

O 

O 

• 

M 

....  S     ...    . 

S 

^ 

\k 

-P 

rtf^S 

-g    •    •    -CQ    -^    •    • 

fi 

a 

.3                      «S   o3 

O 

w 

u 

05 

trace,  Torpo 
on     . 

Plympton 
ton,  Exeter 
diot  Asylum 
ar  Darlingto 
.ear  Gateshe; 

Colchester 

QQ 

aT 

o 

s  "S  flC « 1-^  2  «  a 

o 

0> 

w 

-P  o 

to 

5w 

^w^i^ijgi 

g 

ft 

Xfl 

02 

%-,;>  p-i  <*-^-^  ft  ft  .^  t> 

m 


o  o> 


H 


Provincial  Licensed  Houses. 


531 


Pp4 

IS    . 


.4^  p  S  <^  5 

00  >^   .  o    ^ 

.•  S  .     .  no  .•  02 

rH     H  tj     •_,  tj     -    'F^ 


•  f-i  . 

f^   S  § 
O   O   O 

•IH      tj     fH 

111 

P*   O   o3 

*  ^Ph 


^u      -ill 

s""-!  il 

O  M  w  ^    . 

O  M  [^  d  /?^ 

^.^.'^  §^ 

^  Oi^'S  d 
^^         (5)    g 


^  d  "3  9    .  I)  d 


'7^^    'I' 
o  a)       > 

t,    !-    -- 


"^ 


M  CO      -  o    ^  "    ?„ 


Wij  dp4"  oj  o 
!?QW.d3,H-      ^f 

tjS  d  3(^  dW  orS 

;!Zi   O-H^^O* 


'  PI  <»  ?  5 
o  =s  d  ^ 


p 
^ 


"5     « 


p! 

c3  O 


d  ^3  ?    ^ 


-^  b 


o 


^:gN 


d    •  o 
o  d  j^ 


^   d  33   p   0)   o 

o  .«2  (f  p  S  -^ 

Wr-^  o  M  03 


b    0     M    M 


01 

d 

.f4 

4-* 

,i!i 

d 

m 

c3 

0 

,d 

P4 

«tH 

d 

u 

eS 

0 

0 

^ 

1^ 

^ 

^ 

M 

532 


Insanity  and  Allied  Neuroses. 


% 


P 

O 

W 

m 
o 


I— I 
o 

I— I 

o 

Ph 


M 


CO    5 

t«  .  . 

o    . 

0  TJ  ij  t3 

<ri  o  ^  Pl 


o 


c3      cj:::; 

'^  0-t5^- 
043'  g  01 
<D  H  aj  W 


02  .3 
OS     0 


5  <= 

■   Q  -e 

5  Plh4  o  S  ;^^ 

•V  d  as  c« 

(B  Q>  Fh  .Ad 

■— '  t3  «  0)  .,  f" 

n  "S  0)  02  01  s 

«j  g  >  s  cc  - 


a 


«   O) 


6p^ 


.    .  ;^  0)    - 
\M  ca  pi  ^     ■ 

r-H    a    «    m   ^ 
,   CSM   CD   !=^'^ 


M 


?3  g  ^  -  -, 


Ti 


I"    ^     ^    § 
m    m    ai  ai 


P^ 


H 

t? 

0 

rW 

M 

M 

^ 

>-i 

u 

0 

0 

0 

iH 

>^ 

>^ 

INDEX. 


Absinthe,  Effects  of,  425 

Accident^s  a  cause  of  general  para- 
lysis, 283 

of  insanity,  66 

Accusations,  False,  261 

,  Self-,  471 

Adhesion  of  membranes  in  general 
paralysis,  347 

Affidavit,  Form  of.  (See  Appendix). 

Age,  Influence  of,  in  causing  in- 
sanity, 25 

-,  Old,  as  cause  of  insanity,  76 

Alcobolism  and  general  paralysis, 
279,  339,  420,  425 

as  cause  of  dementia,  217 

of  general  paralysis,  283 

of  insanity,  56,  420 

,  Chronic,  425 

iu  connection  with,  the  ad- 
mission of  patients  into  work- 
houses, 504 

in  connection  with  the  signing 

of  certificates,  502 
,  Restraint  in  connection  with, 

603,  504 
,  Self-restraint  in  connection 

with,  465,  466 
Allbutt,  Dr.  Ciitford  :  alternation 

of  neuroses,  403 
Alleged  lunatics,  Proceedings  in 

respect  to,  513 
Allied  states  to  insanity,  38 
Alternation  between  asthma  and 

insanity,  400 
between  gout  and  insanity,  433 

between  headache  aud  in- 
sanity, 403 

between  phthisis  and  insanity, 

399 

Ambition,  Foolish,  as  cause  of  in- 
sanity, 48 

Amnsesia,  Testamentary  capacity 
with,  476 

Anaasthesia  in  general  paralysis, 
231,  291 


Annoyance,  Complaints  of,  259 
Anxieties,  Business,  46 

cause  of  general  paralysis,  283 

,  Domestic,  44 

,  mental  over-worl^  48 

Aortic  disease  and  insanity,  405 
Aphasia,   Testamentary   capacity 

with,  475 
Apoplexy  and  testamentary  capa- 
city. 475 

,  Hallucinations  preceding,  239 

,  Insanity  following,  351 

,  Senile,  with  mania,  352 

,  varieties,  351 

Aptitudes  in  moral  imbeciles,  275 

,  Special,  7 

Arterial  disease,  392 

,  Syphilitic,  and  insanity, 

392 
Aspect  of  insane,  42 
Assault,  Criminal,  473 
Asthma  and  insanity,  126,  400 

,  cases,  401 

Asylums,  when  necessary,  477 

Atavism,  30 

Ataxic  gait  in  general  paralysis, 

285,  318 
Atrtxy  and  insanity,  359 

,  Cases  of,  859 

:  Dr.  Bristowe,  357 

:  Dr.  Mnhomed,  358 

Autobiographical  sketch  by  a  sub- 
ject of  hallucinations,  244 

of  melancholia,  185 

of  prrsecution,  257 

of  puerperal  insanity,  378 

Ball,  Professor :  paralysis  agitans 

and  insanity,  353 
Beach,     Fletcher :     hypertrophic 

idiocy,  454 

:  sporadic  cretinism,  443 

Bes-gars,  Insanity  rare  in,  35 
Belladonna,  Delirium  of,  followed 

by  insanity,  345 


534 


Insanity  and  Allied  Neuroses. 


Benevolence  in  general  paralysis, 

338 
Betlilem    hospital.  Criminal    lu- 
natics confined  in,  520 
Blackstone  :  exposition  of  law  con- 
cerning criminal  lunatics,  519 
Blandford,  Dr.  :    the    signing    of 

certificates,  501 
Boarders  in  hospitals,  498 
Borrow,  George  :    the  unpardon- 
able sin  ("  Lavengro"),  195 
Brain  concussion  and  idiocy,  453 

fever,  91 

hypochondriasis,  133 

tumour  with  iu  sanity,  389 

Bright's  disease.  Insanity  with,  408 

,  Suicide  from,  210 

,  "Worry  as  cause  of,  45 

Broadmoor   asylum  for  criminal 

lunatics,  521 
Bruising  in  general  paralysis,  294, 

333 
Bucknill,  Dr.,  on  heredity,  37 
Burial  of  pauper  lunatics,  517 

Cachexia,  Syphilitic,  and  insanity, 
392 

, , ,  Description  of  ,392 

Campbell,  Lord  :  chai-ge  to  jury 
concerning  restraint,  493 

Case-book,  Medical  entries  to  be 
made  in,  and  provisions  re- 
specting, 509 

Catalepsy,  181 

Causation,  Definition  of,  16 

of  general  paralysis,  281 

of  mania,  113 

Causes,  Complex,  17 

Exciting  (moral)  : 

domestic,  44 

fright,  55 

grief,  45 

mental  anxiety,  48 

money  troubles,  46 

over-work,  49 

religion,  60 

(physical)  : 

accident,  68 

climacteric,  73 

congenital  defects. 


78 


fevers,  74 

intemperance,  56 

mastiirbation,  63 

old  age,  IQ 

over-exertion,  64 

pregnancy,  67 

privation,  76 

puberty,  72 


Causes,  Exciting  (physical)  : 

, sexual  excess,  59 

, sunstroke,  65 

, unknown,  79 

, uterine  and  ovarian, 

71 

, venereal  disease,  50 

,  Physical,  psychical  (moral), 

17 

,  Fredisposinsr,  general,  18 

■ , , ,  age,  25 

, , ,  education,  21 

, , ,  race,  19 

, , ,  sex,  23 

, ,  hereditary  constitution, 

41 

, ,  neurotic  tendency,  28 

, ,  occupation,  32 

, ,  Special,  37 

, , ,  constitution,  41 

■ , , ,  neurotic  tendency, 

28 

Celts,  Earity  of  general  paralysis 
in,  19 

Certificates,  medical.  Alcoholism 
in  connection  with,  503 

, ,  by  whom  to  be  signed, 

499 

, ,  for  how  long  valid,  499 

, ,  Hints  to  medical  men  as 

to  drawing  up,  £02 

, ,  if  defective  how  to  be 

remedied,  501 

, ,  in  Chancery  cases,  488 

, ,  in  connection  with  hos- 
pitals and  licensed  houses,  499 

,  ,  objecting  of  commis- 
sioners, 501 

,  ,   Penalties    respecting, 

600 

, ,  Proceedings  of  commis- 
sioners in  reference  to,  501 

, ,  provisions  relating  to 

such  persons,  499 

, ,  rules  to  be  observed,  502 

,  ,  separate    examination 

necessary,  500 

. , ,  Strategy  undesirable  in 

respect  to,  502 

• ,  ,  Strict  provisions  con- 
cerning, 601 

, ,  to  be  forwarded  to  Com- 
missioners, 500,  501 

, ,  Treatment  without,  477 

, ,  two  required,  499 

of  death  to  be  forwarded  to 

Commissioners,  616 

Chancery  lunatics,  Provisions  con- 
cerning, 488,  et  seq. 


Index. 


535 


Chart,  Temperature,  in  man' a,  98 
Childless   women,   General    para- 
lysis in,  303 
Chloral  crave,  429 

habit,  428 

,  Suicidal  tendencies  due  to,429 

Chorea  and  insanity,  391 
Chronic  insanity.  225 
Classificatiou  of  insanity,  10 

of  lunatics.    (See  Lunatics.) 

,  Provisional,  12 

,  Scheme  of,  11 

Climacteric,  73,  200 
Clouston,Dr.,on  delirium  tremens, 

604 
Collateral  inheritance,  82 
Commission  in  lunacv,  488 

,  Costs  of,  490 

,  Description  of,  489 

,  Medical  certificates  in 

connection  with,  489 

,  nature  of  verdict,  489 

,  Notice  of  to  be  sent  to 

alleged  lunatics,  490 
,  proceedings   after   cus- 
tody of  person,  490 

. ,  where  desirable  to   be 

held,  492 
Commissioners  in  Lunacy,  485 
,   documents  to   be  for- 
warded for  their  inspection,  509 

,  Duties  of,  487,  et  seq^. 

,  history  of  appointment 

of,  486 

,  Jurisdiction  of,  ^ 

,  objects  of  their  visita- 
tion, etc.,  etc.,  507,  508.  (See 
chapter  xxiv.,  page  483.) 

,  proceedings  in  reference 

to  certificates,  501 

,  their  power  of  granting 

licenses,  496 

. ,  their  power  of  prose- 

cutiog    for    non-observance    of 
regulations,  500 

,  their  regulations  con- 

cerniag    the    management     of 
asylums,  501 

,     their     visitation     of 

county  asylums,  512 
,  their  visitation  of  regis- 
tered   hospitals     and    licensed 
houses,  503 

,  Metropolitan,  486 

"  Committees,"  persons  appointed 
to  take    charge    of     Chancery 
patients,  4£0 
Confidence,  Loss  of,  in  dementia, 
211 


Conium  in  recurrent  mania,  233 

Continence,  Effects  of,  55 

Convulsions  cause  of  idiocy,  446 

in  general  paralysis,  289,  334 

Costs  of  commission  in  lunacy,  490 

County  asylums,  510 

,  Administration  of,  511, 

et  seq, 

(-Foi-  /wrtfier  particulars  see  Places 
of  confinement  for  the  insane. ) 

Court  of  Appeal,  484 

Cravings  for  drink,  427 

for  opium  and  morphia,  430 

• of  pregnancy,  67 

Cretinism,  456 

,  Sporadic,  443 

Crime  and  insanity,  8 

in  connection  with  al- 
coholism, 465 

in  connection  with  forms 

of  disease,  43,  et  seq. 

in  connection  with  re- 
straint of  lunatics,  520 

in  connection  with  self- 
indulgence,  465,  466 

in  connection  with  self- 
restraint,  465.  469 

,    proceedings    in   regard    to 

those  prevented  from  commit- 
ting-, 519 
Criminal  lunatics,  Places  of  con- 
finement for,  519 

,  Provisions  concerning, 

520 

,  their  various  classes,  519 

Cure  in  mania,  119 

Dahl,  Ludwig,  on  idiot  descent,440 
Death  of  patients,   Provisions  of 

Commissioners  on,  516 
Defects,  congenital.  Effect  of,  78 

,  Some  bodily,  79 

Degeneration,  Neurosis  from,  31 
Delirium  of  belladonna  followed 

by  insanity,  435 

tremens  and  insanity,  422 

,  Nece-sity   of    restraint 

for  persons  suffering  tinder,  503 
Delivery,  Insanity  of,  370 
Delusional  insanity,  237 
Delusions,  medico-legal  relations, 

464 
Denientia,Acute,  and  melancholia; 

, primary,  210 

,  Alcoholic,  217 

and  amentia,  207 

,  Degrees  of,  207 

,  Diagnosis  of,  220 


536         Insanity  and  Allied  Neuroses. 


Dementia,  Epilepsy  and,  218 

from     physical     or     mental 

disease,  216 

,  Hypochondriacal,  235 

,  Nature  .  f ,  207 

of  general  paralysis,  289,  295, 

312 

,  Partial,  211 

,  Post  apoplectic,  351 

, ,  Diagnosis  of,  from 

general  paralysis,  841 

—^,  Primary  and  secondary,  208 

,  seC'  'ndary  and  cliroxiic, Varie- 
ties and  cases  of,  225 

,  SypMlitic,  217,  393 

-^,  Treatment  of,  220 

,  Typical,  209 

,  with  outburst  of  mania,  225 

Depression  before  mania,  114 

Deprivation,  Idiocy  by,  455 

Diai'etes  and  insanity,  411 

Dickinson,  Dr.,  on  diabetes,  411 

Dipsomania,  37,  427 

Dirt,  Feeling  of,  249 

Disseminated  sclea  osis  and  general 
paralysis,  3i2 

and  insanity,  390 

Double  consciousness  in  epilepsy, 
385 

form  of  insanity  in   general 

paralysis,  325 

Down,  Dr.  Langdon :  intemper- 
ance in  parents,  441 

, :  types  i  f  idiocy,  487 

Dysentery,  Hypochondriasis  fol- 
lowing, 149 

Eccentricity,  3 

,  Varieties  of,  4 

Eclampsic  idiocy,  446 

Edmunds,  Dr.  :  optic  nerves  in 
general  paralysis,  328 

Education  as  cause  of  insanity,  21 

,  Bad,  22 

in  epilepsy,  389,  481 

iu  neurotic  children,  480 

Ego,  Feeling  of,  129 

in  melancholia,  156 

Emoti'nal  disturbance  in  general 
paralysis,  337 

jSpi'epsie  larvee,  385 

,  cases,  387 

Epilepsy,  124 

and  dementia,  218,  383 

and  epileptic  mania,  384 

,  Diagnosis  from  general  para- 
lysis, 342 

,  Effect  of  fits  of,  383 

,  Idiocy  from,  4i6 


Epilerisy  related  to  insanity,  382 

,  Syphilitic,  392 

,  Treatment  of,  388 

Epileptic  idiots,  446 
Epileptics,  Bnitality  of,  383 

,  Intractability  of,  448 

,  Prognosis  of,  bad,  448 

Escape  of  lunatics,  514 

,  Provisions    concerning, 

514 
Exaltation  of  ideas.  Growth,  of, 

263 

in  delusional  insanity,  262 

in  general  paralysis,  338 

Excess,  Sexual,  59 

Excitement,  religious,  Effect  of,  50 

Exophthalmic  goitre  and  insanity, 

412 
with  general    paralysis, 

415 
with  recurrent  mania,  415 


je.  Dr.  Hilton :  sporadic  cre- 
tinism, 443 

Farmers,  Insanity  in,  .33 

Feeding  in  melancholia,  142 

Fevers  as  cause  of  insanity,  74 

,  Delirium  of,  75 

,  Dementia  of,  216 

,  Post-febrile,  435 

Fisherton  House,  near  Salisbiiry, 
for  criminal  lunatics,  521 

Fits  in  general  paralysis,  292 

,  Varieties  of,  293,  334 

Folie  a  deux,  472 

circulaire,  122 

Food,  Eefusal  of,  141,  153,  171 

Fright  as  cause  ot  insanity,  55 

,  Case  of,  55 

Galvanism,  Ideas  of,  244 
Gasquet,   Dr. :    case    of  dissemi- 
nated multiple  sclerosis  and  in- 
saaiity,  390 
Gen  ral  paralysis,  Acute,  297 

,  Ataxic,  317 

,  Causation  of,  281 

,  Chronic,  298 

,  Convulsions  in,  334 

,  Den  rented,  295,  312 

,  J  i  gnosis  of,  339 

,  Double  form  of,  325 

' ,  Dr.  Maudsley  on  pro- 
gressive degeneration  in,  279 

,  Dr.  JVlicMe  on,  278 

,  effects  on  oiispring,  41 

,  First  stage  of,  290 

— '■ from  over-strain,  65 

,  Hypochondriacal,  295 


Index, 


537 


General  paralysis.  Ideas  of  grand- 
eur in,  338 

,  Initial  symptoms  of,  288 

in  a  single  girl,  306,  308 

in  w(  iman,  302 

,  lateral  sclerosis,  exam- 
ples of,  318,  320 

,Loss  of  self-controlin,  337 

,  Maniacal  stage  of,  123 

not  an  ordinary  netirosis, 

41 

,  Ordinary  case  of,  299 

,  Pathology  of,  345 

,  Physical  basis  of,  376 

,  Prodromata  of,  386 

,  Prognosis  of,  3J3 

,  Eemission  of,  304,  321 

,  Second  stage  of,  292 

,  Senile,  311 

■ ,  Speech  in,  329 

,  Spinal,  316 

• •,  Stages  of,  289,  388 

,  Symptoms  in  detail  of, 

007 

,  Syphilitic,  395 

,  Temperature  in,  336 

,  Third  st;ige  of,  294 

,  Treatment  of,  34i 

- — ,  Tremor  in,  329 

,  Urine  in,  337 

,  Varieties  of,  278,  284 

,  with  exophthalmos,  415 

,  with  little  tremor,  315 

,  with  pregnancy,  369 

,  without    mental  symiD- 

toms,  277,  280 

,  Writing  in,  330 

Genetous  idiocy,  442 

,  altered  race-type  of,  Dr. 

Down  on,  443 
Genius  and  insanity,  5,  275 

,  Varieties  of,  5 

Girl,  General  paralysis  in  young, 

306,  308 
Glycosuria  in  insanity,  411 

,  Cases  of,  412 

Goitre,  412,  415,  4*6,  457 
Goulds  tone.  Case  of,  471 
Gout  and  insanity,  433 

and  melancholia,  206 

Governesses,  Insanity  in,  34,  49 
Gowers,  Dr.,  on  chorea,  391 
Grandeur,    Ideas    of,   in    general 

paralysis,  338 
Graves's  disease  and  insanity,  412 
Grief  as  cause  of  insanity,  45 

,  Action  of,  45 

Gummata  producing  insanity,  392, 

394 


Hsematomata  in  general  paralysis, 

333 
Hsemoi-rhage  into  spine  in  genera] 

paralysis,  304 
Hallucinations,  Case  of  acute,  242 

in  delusional  insanity,  238 

in  general  paralysis,  290 

in  mania,  102 

of  feeling,  24i 

of  hearinar,  Varieties  of^  240 

of  sight,  212 

of  suiell  and  taste,  243 

Hand-writing  in  general  paralysis, 

332 
Hearing  in  general  paralysis,  328 
Heart  disease  and  insanity,  404 

and  melancholia,  206 

,  Aortic,    exaltation    or 

melanchoha.  406 
,  Mitral,  and  melancholia, 

405 
Heredity  as  cause  of  insanity,  37 
Heron,    Dr.  :    case     of    youthful 

melancliolia,  28 
"  Hints,"  Danger  of,  193 
Histological  changes,  Unsatisfac- 

to  y,  9 
Holy  Ghost,  Sin  against  the,  195 
Home  treatment,  480 
,  Directions    concerning, 

481 

,  where  desirable,  480 

Homicide,  487 

,  impulses  in  delusional  cases, 

468 

owing  to  "  influence,"  468 

owing  to  weak-minded- 
ness, 468 
Hospitals,  Eegistered,  497 

.     (Spb  Appendix,) 

House  of  Commons  :  inquiry  into 

condition  of  pauper  and  criminal 

lunatics,  520 
Hunter    v.    Hunter :    nullity   of 

marriage,  360 
Huth,    Mr.,    on    consanguineous 

marriages,  440 
Hydrocephalic  idiocy,  249 
Hydrocephalus  with  insanity,  449 
Hypergesthesia  and  general  para- 
lysis, 291 
Hypertrophic  idiocv,  454 
Hypochondria' -al  dementia,  235 
Hypochondr  asis,  128 

,  Brain,  133 

, ,  Case  of,  134 

,  form  of  general  paralysis,  295 

,  ga-^tric.  Varieties  of,  137 

,  Prognosis  of,  133 


538 


Insanity  and  Allied  Neuroses. 


Hypochondriasis  rare  in  women, 

149 

,  Eesults  of.  133 

• ,  Sexual,  145 

• , ,  Case  of,  146 

stage   of    general    paralysis, 

285,  288 

.  Symptoms  of,  132 

,  Treatment  of.  144 

,  Varieties  of,  131 

,  SypMlitic,  392 

Hysteria,  80 

,  alternation  with,  insanity,  82 

,  insane  families,  81 

,  massage,  treatment  by,  90 

rare  in  asylums,  81 

,  Treatment  of,  85 

with  sense  perversion,  83 

Hysterical     mania     and    melan- 

cbolia,  95 
Hystero-epilepsy,  86 
,  Cases  of,  88 

Idiocy,  437 

■ by  deprivation,  455 

,  Classification  of,  438 

■ ,  cretinism,  456 

,  Eclampsic,  4i6 

■ ,  Epileptic,  446 

,  Genetous,  442 

,  Hydrocephalic,  449 

,  Inflammatory,  454 

,  Microcephalic,  444 

,  neurotic  inheritance,  439 

- — -,  Paralytic,  452 

— — ,  sporadic  cretinism,  443 

,  Traumatic,  453 

Idiot  savant,  438 

,  Acute  insanity  in,  459 

Imagination  in  mania,  106 

Imbeciles,  437 

Imbecility,  454,  459 

Impotence,  Ideas  of,  145 

Impulse  in  epilepsy,  383 

,  medico-legal  aspect  of,  463, 

464 
Incoherence  in  mania,  109 

,  Case  of  chronic,  226 

,  Chronic,  120 

Indians,  Insanity  in,  20 

Infanticide,  470 

owing  to  ignorance  of  birth, 

470 
owing  to  puerperal  insanity, 

470,  471 
Inflammatory  idiocy,  453 
Influence,  Undue,  in  wills,  474 
Inheritance,  Direct,  29 
- — ,  Neurotic,  28 


Inheritance,  Drink-craving,  424 

Injunction  of  Lord  Chancellor, 
492 

Injuries  cause  of  general  paralysis, 
282 

,  mode  of  action,  67 

to  head  as  causes  of  insanity 

in  parent  or  child,  40,  QQ 

Inquisition,  Description  of,  484 

,  traverse     of    within    three 

months,  490 

Inquisitiveness  as  symptom  of  in- 
sanity, 256 

Insanity,  alternating  with  hys- 
teria, 82 

,  Definition  of,  1 

of  development,  adolescence, 

maturity,  decay,  14 

,  Relativity  of,-  2 

Intemperance,  alcohol  as  cause  of 
insanity,  56 

in  parent  as  cause  of  idiocy 

in  children,  441 

,  modes  of  action  as  cause,  57 

Ireland,  Dr.,  on  idiocy,  437 

,  on  treatment,  444,  446,  419, 

452,  456,  458,  459 

Jealousy,  Case  of,  264 

due  to  drink,  427 

in  delus.onal  icrsanity,   263 

Jury,  verdict  in  commission  in 
lunacy,  489 

Kidney,  Disease  of,  and  insanity, 
407 

,  no  special  form  of  in- 
sanity depending  on,  408 

,  suicide,  410 

Kleptomania,  271,  466 

from  drink,  427 

Lactation,  Insanity  of,  379 

,  cause,  symptoms,  examples, 

prognosis,  380 

Lateral  sclerosis  in  general  para- 
lysis, 319 

,  case,  man,  319 

, ,  woman,  320 

"Lavenaro,"  195 

Lawford,  optic  nerves  in  general 
paralysis,  328 

Lead  poisoning  and  general  para- 
lysis, 340 

,  Insanity  due  to,  431 

,  mania,  epilepsy,  general 

paralysis,  432 

Legal  responsibility,  460 


Index. 


539 


Legal  responsibility  in  connection 

vvitli  delusion,  463 
■ ,  main  provisions  of  law 

witli  respect  to,  462 
■ ,  Reference  to  question  of, 

460  ei  seq. 
,  relationship  with  prin- 
ciples of  criminal  law,  460 
,  suggestions  concerning 

medical    side  of   question,  462, 

463 
,  where  defective    know- 
ledge of  right  and  wrong,  462 
Letter  describiug  hallucinations, 

255 

of  melancholiac,  157 

Letters  of  lunatics  to  be  retained 

for  inspection  if  not  forwarded, 

509 
Lips,     Tremor     of,     in     general 

paralysis,  329 
Lochia  in  inierperal  insanity,  355 
Locomotor     ataxy    and    general 

paralysis,  285,  318 
Lord  Chancellor,  Functions  of,  484 
■ .management of  Chancery 

patients,  488 
Love  as  cause  of  insanity,  54 
Lunatics,  burial  of,  516 

,  Cijaucery,  488 

,  Crimes  committed  by,  467  et 

seq.,  519,  520 

■ ,  Criminal,  537 

,  Dangerous,  517 

,  Death  of,  516 

,  Escape  of,  514 

,  Home  treatment  of,  477 

,  ni-treatment  of,  493 

, ,  cases  in  point,  493, 

494 

■ in  worthouses,  516 

,  Marriage  of,  483 

,  Pauper,  509 

,  Piivate,  488 

,  Recovery  of,  514 

■ ,  Eettirn    to    occupation   of, 

482 

,  Self-restraint  of,  465 

,  Superintendence  of,  by  state, 

484 

• ,  Temporary  abseaace  of,  515 

,  Testamentary  capacity  of, 473 

,  Transfer  of,  516 

■ ,  treatment    without    certifi- 
cates, 480 

,  Visitation  of,  506 

,  Wandering,  518 

,  what    persons    desirable  to 

make  Chancery  lunatics,  491 


Lunatics  with  relations  or  friends, 

493 
{For  further  particulars  see  Places 

of  confinem.ent  for  the  insane) 
Lust  in  early  general  paralysis,  288 
Luxmore,  Charles,  case  of,  493 

Magnetism,  Ideas  of,  244 

Malleation,  89 

Mania,  Acute,  91 

, ,  Conditions  of,  99 

, ,  Varieties  of.  111 

,  bodily  symptoms,  100 

,  causation,  113 

,  Chronic,  224 

, ,  and  general  paralysis, 

340 

,  Delirious,  93 

,  Descrii3tion  of,  92 

,  diagnosis,  98 

,  duration,  115 

,  Epilepsy  and,  124 

following  apoplexy,  352 

,  Case  of,  355 

,  Hysterical,  91 

,  lead  poisoning,  432 

,  mental  symptoms,  101 

,  pathology,  126 

,  prognosis,  117 

,  Puerperal,  360 

— —  stage  of  folie  circulaire,  122 

,  stages,  114 

,  Transitopia-puerperal,  371 

,  Treatment  of,  97 

Marriage  among  insane,  483 

and  insanity,  25 

,  Consanguineous,  440 

,  Insanity  due  to,  361 

, following,  360 

,  Nullity  of,  361 

Massage,  90 

Masters  in  Liinacy,  484 

IMastnrbation,  63,  145 

Maturity,  Insanity  of,  27 

Maudsley :  borderland  of  in- 
sanity, 7 

:  diabetes  and  insanity,  411 

:  epilepsy,  385 

on  general  paralysis,  279 

Melancholia,  Active,  175 

, ,  Chronic,  176 

,  autobiography     of   patieat, 

185 

,  catalejjsy,  181 

,  Chronic,  203 

,  Conditions  of,  151 

,  Course  of  simple,  168 

,  Delinitioii  of,  151 

,  Divisions  of,  152 


54<^ 


Insanity  and  Allied  Neuroses. 


Melancliolia,       explanations       of 

symptoms,  184 

,  Hypochondriacal,  128 

,  Hysterical,  75 

,  letter  of  patient,  157 

,  Mental,  155 

,  Passive,  178 

,  Physical,  152 

,  Puerperal,  377 

,  recovery,  163 

,  Eecnrreut,  203 

,  remissions,  171 

;  resulrs,  165 

,  Senile,  201 

,  Sensory,  154 

,  Simple,  172 

,  Special  forms  of,  1 '  7 

,  Stages  of,  163 

,  sudden  cure,  164 

,  symptoms,  152 

,  treatment,  200 

,  with,  bodily  disease,  162 

,  with  general  paralysis,  3:3 

,  with  stupor,  179,  182 

Membranes,  Adhesions  of,  347 
Memory,  Acute  loss  of,  214 

,  Loss  of,  affecting  wills,  475 

, ,  in  dementia,  213 

Mental  weakness.  States  of,  221' 
,  Testamentary  capacity 

in,  475 
,  Varieties  of  causes  of, 

221 

,  with  chronic  mania,  224 

Metropolitan  Commissioners,   in 

what    manner    differing    from 

Lunacy  Commissioners,  486 
Mickle,  Dr. :  diagnosis  of  general 

paralysis,  342 
,  ,  on  general   paralysis, 

279,  285 
Microcephalic  idiocy,  444 
,  resemblance  of  patients 

to  animals,  445 
Milk  in  puerperal  insanity,  374 
Mitral   disease  and  melancholia, 

404 
Money  losses,  cause  and   symp- 
toms of  insanity,  47 
Monomania,  119 
Monotonous  work,  Effect  of,  £0 
Moon,  Einfeet  of,  36 
Mural  insanity,  7,  269 

,  Cases  of,  275 

,  Classes  of,  271 

due  to    insane    inheri- 
tance, 273 

from  drink,  421 

,  Nature  of,  270 


Moral  insanity,  precocity  or  abil- 
ity, 275 

,  training,  9 

,  with  cruelty,  274 

Morbus  cordis.  (See  Heart  dis- 
ease.) 

Morphia,  symptoms  and  treat- 
ment, 430 

Multiple  sclerosis  and  insanity, 
390 

Murder,  Causation  of,  467,  468 

,  Relationship    of,  to  mental 

perversion,  468 

Muscles  in  general  paralysis,  331 

,  wasting  in  dementia,  234 

Musical  aptitude  in  moral  imbe- 
ciles, 275 

Myxoedema  (Ord),  213 

• ,  Case  of,  418 

,  Symptoms  of,  9 

with  dementia,  417 

with  insanity,  416 

Narcotics,  Effects  of,  58 

in  mania,  116 

"  Ne'er-do-weels,"  9 

Negroes,  General  paralysis  in,  20 

Neurosis,  Alternation  of,  400 

:  Dr.  Chfford  All  butt  on,  403 

from  degeneration,  31 

of  degeneration,  39 

started  by  injury,  40 

Neurotic  inheritance  of  idiots, 
439 

Nomenclature,  College  of  Physi- 
cians, 11 

Notices  of  admission  to  asylums, 
495 

of  death  or  recovery  to  be 

forwarded  to  Commissioners, 
51-t,  516 

Nullity  of  marriage  from  in- 
sanity, 361 

Occupation  as  cause  of  insanity, 
32 

■ ,  Precarious,  33 

,  Return  to,  when  desirable, 

482 

Opium  crave,  429 

Optic  disc  in  general  paralysis, 
327 

in  syphilis,  393 

Ord,  Dr. :  Dementia  in  myx- 
oedema, 213 

,  on  contraction  of   sigmoid 

flexure,  141 

Orders  of  admission  into  county 
asylums,  513 


Index, 


541 


Orders  of  admission  into  un- 
licensed bouses,  494 

to  be  forwarded  to  Com- 
missioners, 495 

Ovarian  disease  as  cause  of  in- 
sanity, 71 

Over-exertion,  49 

pressure  in  education,  22 

work,  Cause  of,  49 

,  Nature  of,  49 

,  rare  as  cause  of  insan- 
ity, 49 

Pacbymeningitis,     Cases     of     in 

general  paralysis,  310,  311,  346 
Palate  in  genetous  idiots,  442 
Paralysis  agitans  and  insanitj',  356 
Paralytic  idiocy,  452 

insanity,  351 

Parturition,  Insanity  of,  69 
Pauper  lunatics,  609 

in  workbouses,  516 

,   Places  of  confinement 

for,  510 
,  Regulations  concerning, 

510  et  seq. 
"Persecution,"  Ca=!e  of,  257 

from  drink,  421 

,  Ideas  of,  286 

Pbtbisis,  absence  of  symptoms  in 

insanity,  396 

and  insanity,  396 

,  sanity  before  deatb,  40O 

,  suspicion,  irritability,  refusal 

of  food,  398 
Pierret :  locomotor  ataxy,  357 
Places  of  confinement  for  criminal 

lunatics,  519 

■ for  tbe  insane  : 

County  and  borougb  asylums, 

510 
,  Gradual  growth 


of,  510 
512 


-,  Management  of, 


,  manner  of  ad- 
mission, 513 

^  proceedings  of 

justices  and  relieving  offi- 
cers, 513 

,   tbe  admission 

of  patients,  not  paupers, 
517 

• ,  wbat  persons  to 

be  admitted,  513 

Licensed  bouses,  or  private 
asylums,  495 

• ,  ,  Advan- 
tages of,  495 


Places    of    confinement    for    the 
insane : 
Licensed  bouses,   or  private 
asylums,    Management    of, 
496 

, .  Eegula- 

tioQS  concerning,  493 
Registered  hospitals,  497 

,  class  of  individuals 

for  whom  deigned,  497 

,  Management  of,  497 

,    Regulations     con- 
cerning, 497 

• ,  relation  to  lunacy 

laws,  497 

,  Voluntary  boarders 

in,  498 
Under  single  care,  493 
(For  full  particulars  concern- 
ing procedure  in  respect  to 
management  of  such  places 
see  chapter  xxiv.) 
Pneumonia,  followed  by  insanity, 

435 
PoisoninsT  from  alcoholism,  426 

■ ',  Ideas  of,  243 

Practical  and  social  questions,  477 

et  seq. 
Precocity,  5,  275 

and  genius,  6 

Pregnancy  as  cause  of  insanity,  67 

,  cases,  357 

,  General  paralysis  with,  369 

,  Insanity  of,  363 

,  mode  of  action,  68 

,  symptoms,  335 

,  varieties,  3S4 

Premature  labour.  Induction  of, 

not  justified,  366 
Primogenitare,  Risks  of,  453 
Prisooers,  Insanity  in,  36 
Private  lunatics,  488 

,  Ill-treatment  of,  493,  514 

,  Regulations  concei-ning, 

488 
Privation  as  cause  of  insanity,  76 
Prostitutes,  Insanity  common  in, 

35 
Pseudo  -  hypertrophic     paralysis 

and  imbecility,  453 
Puberty  as  cause  of  insanity,  26,  72 
Puerperal  insanity,  69,  360,  371 

,  causation,  371 

,  form,  371 

,  lochia,  374 

,  milk,  374 

,  prognosis,  375 

,  pyaemia,  372 

— — ,  treatment,  376 


542 


Insanity  and  Allied  Neuroses. 


£*uerperal  melanciiolia,  377 

Punning  in  mania,  107 

PtipUs  in  general  paralysis,  291, 

327 
Pursued,  Ideas  of  being,  261,  421 
Pyaemia  in  puerperal  insanity,  372 
Pyromania,  ^Q 

Queens  of  asylums,  262 

Race,  Effect  of,  19 
Eape  by  tbe  insane,  472 
Kayner  :  lead  and  insanity,  340 

:  pbtbisis  and  insanity,  397 

Recovery,  Late,  in  melancbolia, 

205 
• of  patients.  Charitable  fund  in 

respect  to,  515 

in  county  asylums,  515 

in  licensed  house  or  regis- 
tered hospital,  514 
Reflexes  in  general  paralysis,  291 
Ri  gistrar  in  lunacy,  484 
Relapses  in  mania,  117 
Religious  excitement  as  cause  of 

insanity,  60 

ideas  in  melancholia,  159,  194 

,  Origin  of,  52 

Remissions  in  general  paralysis. 

Case  of,  304,  321,  323 

in  melancholia,  171 

not  cure,  322 

Renal   disease   and  melancholia, 

206 
Responsibilitj^     of     patients      in 
asylums    in    connection  with 
alcohohsm,  465,  503 
• in  connection  with  vari- 
ous forms  of  disease,  466 
(For  furtTiav  %'iarticulars  see  Legal 

responsibility.) 
Restlessness  in  general  paralysis, 

290 
Retreats  for  habitual  drunkards. 

Provisions  respecting,  605 
Rheumatic  fever   and    dementia, 
.    216 

and  insanity,  404 

Roberts,  Evan,  Case  of,  493 

Sclerosis,  Disseminated,  and 
general  paralysis,  342 

,  Insanity  witb,  390 

Scrofula  and  idiocy,  441 

Secretary  of  State,  liis  govern- 
ment of  criminal  lunatics,  521 

Seduction,  55 

as  cause  of  insanity  in  puer- 
peral cases,  373 


Self-accusation,  owing  to  intem- 
perance, 472 

,  owing  to  mental  depres- 
sion and  restlessness,  472 

control.  Extension  of  prin- 
ciple of  to  criminal  matters  un- 
desirable, 465 

,  Loss  of,  as  a  symptom  of 

disease,  464 

, ,    in    asylums    and 

hospitals,  465 

,  ,  in  general  para- 
lysis, 279,  337 

,  Self-indulgence  m  con- 
nection with,  463 

education,  Some  evUs  from, 

49 

feeling,  128 

Senile  melancholia,  174,  2'">1 

Sense,  Loss  of,  cause  of  idiocy,  455 

,  Perversion  of,  in  hysteria,  83 

Sex,  Influence  of,  23 

, ,  in  me  aucholia,  170 

, ,  ta   puberty,  marriage, 

widowhood,  24 

Sexual  desire  in  general  paralysis, 
291 

excess  as  cause  of  insanity, 

59,  282 

self-abuse  as  cause  of  insanity, 

63,  283 

Shaw,  Dr.  Claye:  ulcer  of  duo- 
denum, 142 

Shock,  moral,  Effect  of,  55,  362 

Shuttleworth,  Dr.  :  eclamiDsic 
idiocy,  446 

Sin,  The  unpardonable,  194 

, ,  George  Borrow  on,  195 

Single  care,  Cases  of  ill-treatment 
with  respect  to,  493 

,  Confinement  of  lunatics 

under,  493 

,  Treatment  under,  480 

Skin  in  general  paralysis,  291,  339 

Smell,  Hallucinations  of,  in  gene- 
ral paralysis,  328 

Social  position  in  relation  to  in- 
sanity, 32 

Solitude  cause  of  insanity,  32 

Speculators,  Insanity  in,  33 

Speech,  Change  of,  in  general 
paralysis,  329 

, , ,  cases,  318 

, , ,  varieties,  317 

Spermatorrhoea,  145 

Spinal  cord  in  general  paralysis, 
348 

— —  general  paralysis,  316 

Starvation  as  cause  of  insanity,  7G 


Index. 


543 


strabismus  in  general  paralysis, 

327 
Stupor,  Melancholia  with,  179 

and  dementia,  180,  183 

Suicide  in  melancholia,   159,  161, 

169,  188 

and  responsibility,  468 

Sunstroke  as   cause  of  insanity, 

65 
Suspicion,  Simple,  251,  476 

,  with  phthisis,  399 

Sutton,  Dr.  :   worry  as  cause   of 

Bright's  disease,  45 
Swallowing,      Difficulty     of,      in 

general  paralysis,  294 
,  Habit  of,  in  general  paralysis, 

349 
Symbolism,  265 
in  delusional  insanity,  Cases 

of,  267 
Sympathetic    system    in    general 

paralysis,  349 
Syphilis    as    cause    of    dementia, 

217 

,  case  of  general  paralysis,  285 

, of  iiisaiiity,  60 

,  Diagnosis  of,  from  general 

paralysis,  3l0 

,  Effect  on  arteries  of,  392 

, on  vision,  causing  gene- 
ral paralysis,  393 

,  Modes  of  action  of,  61 

,  Moral  action  of,  392 

Syphilophobia,  392 

Taste,  Hallucinations  of.  (S?e 
Hallucinations. ) 

in  gpneral  paralysis,  328 

Teeth,  Grinding  of,  in  general 
paralysis,  293 

Teething  convulsions  cause  of 
idiocy,  446 

Teetotalism,  Influence  of,  on  in- 
sanity, 58 

Telephones,  Delusions  about,  241 

Temperament  as  cause  of  insanity, 
41 

Temperature  chart  in  general  para- 
lysis, 292,  336 

in  mania,  98 

Testamentary  capacity,  473 

defective,  in  consequence 

of  aphasia,  476 

. ,  in  consequence  of 

apoplexy,  475 

■ ,  in  consequence  of 

defective  memory,  475 

• ,  in  consequence   of 

delusion  of  suspicion,  473 


Testamentary  capacity  defective 
in  consequence  of  emotions  and 
passions,  476 

,  in  consequence  of 

"influence,"  476 

,  in  consequence  of 

results  of  maniacal  attacks,  476 

,  in  consequence  of 

weak-mindedness,  474,  475 

Theft  as  symptom  of  mental  dis- 
order, 466 

Thoughts  heard  by  others,  241 

Throat  hypochondriasis,  138 

Tongue  in  general  paralysis,  291 

Transfer  of  patients  from  one 
place  of  confinement  to  another, 
516 

,  Persons  willing  to  con- 
tract for,  516 

of  pauper  lunatics,  516 

Traumatic  cause  of  general  para- 
lysis, 283 

idiocy,  453 

Travelling,  for  what  class  of 
patients  desirable,  478 

Treatment  at  home,  480 

by  sea  voyages  and  travelling, 

479 

in  asylum,  477 

in  single  care,  477,  480 

of  adolescent  insanity,  479 

of  dementia,  220 

of  epilepsy,  38S 

of  general  paralysis,  344 

of  hypochondriasis,  144 

of  idiocy,  438,  455 

of  mania,  97 

of  melancholia,  169 

Tremor  of  tongue  in  general 
paralysis,  291,  329 

Tumour.     (See  iirain-tumour. ) 

,  Diagnosis   of,   from  genera] 

paralysis,  342 

,  Symptoms  from,  389 

Typhoid  fever  and  dementia,  216 

Typhomania,  91 

Unknown  causes.  (See  Causation.) 
Unnatural  offences,  472 
Unpardonable  sin.  The,  194 
Unworthiness,  53 
Urine  in  general  paralysis,  292 
,    Dr.      Crichton 

Browne  on,  357 
Uterine    disorders    as    cause    of 

insanity,  71 

Venereal  disease.     (See  Syphilis.) 
Virility,  Fear  of  loas  of,  250 


544 


Insanity  and  Allied  Neuroses. 


Visions,  242 

Visitation,  Objects  of  commis- 
sioners', 508 

of     county    and     borough 

asylums,  512 

of  houses  beyond  metropo- 
litan jurisdiction,  507 

of  medical  attendants,  497 

of  private  lunatics,  490 

of  registered   hospitals   and 

licensed  houses,  506 

Visitors  of  Chancery  lunatics,  490 

Voisin  :  loss  of  smell  in  general 
paralysis,  328 

:  melancholic  general  para- 
lysis, 313 

Voluntary  boarders  in  hospitals, 
498 

Wandering  lunatics,  518 

— '■ ,  Provisions  with  regard 

to,  518 


"Weakness.  (See  Mental  weak- 
ness, and  Dementia.) 

Wealth,  Influence  of,  on  treatment 
of  insanity,  479,  481 

Weaning,  Insanity  of,  379 

White,  Dr.  Hale  :  changes  in  dia- 

Widowhood,  Effect  of,  25 
Will,  Loss  of,  in  dementia,  213 
Words,    Clipping  of,    in.    general 

paralysis,  288 
Workhouses,  Class  of  patients  not 

to  be  admitted  to,  517 
,  Dangerous  lunatics  not  to  be 

confined  in,  517 

,  Pauper  lunatics  in,  517 

,  Separate  wards  in,  517 

Worry     as     cause    of     Bright's 

disease,  45 
of    general    paralysis, 

283 
of  insanity,  44 


CASBELL   ANl'    COMPANY,   LIMITED,    BELLE    SAUVAGE    WOr.KS,   LONIMN,   "5.C. 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

*      tQ95 

MOM  ^  '^  ^^ 

95 

01 

y\  0  ^  ^^^ 

\\\j » 

■«a^ 

00. 

C2e(23B)MI00 

Sa9 


RC601 
Savage 


N 


COLUMBIA  UNIVERSITY  UBRARip 


0037570838 


T%m. 


'  f,  .-'t^••■•; 


v>  -!^ 


'.'^i^-'.^.-^;-: 


